- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $6,918.31 / $19,054.61
| Facility | | $3,388.44 | $6,918.31 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | AS | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,498.45 / $19,498.45 / $19,498.45
| Facility | | $19,498.45 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $12,302.69 / $28,183.83
| Facility | | $10,471.29 | $12,302.69 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $2,290.87
| Professional | | $1,202.26 | $1,584.89 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $15,848.93 / $19,498.45
| Facility | | $4,466.84 | $15,848.93 | $19,498.45 |