- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $6,760.83 / $13,803.84
| Facility | | $2,630.27 | $6,760.83 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,890.45 / $13,182.57
| Facility | | $1,230.27 | $3,890.45 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $6,918.31 / $10,000.00
| Facility | | $1,380.38 | $6,918.31 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | AS | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $3,467.37
| Professional | | $660.69 | $870.96 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $24.55 / $24.55 / $24.55
| Professional | AS | $24.55 | $24.55 | $24.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $8,912.51 / $8,912.51
| Facility | | $3,715.35 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,754.40 / $13,182.57
| Facility | | $1,513.56 | $5,754.40 | $13,182.57 |