- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $10,232.93 / $19,054.61
| Facility | | $7,943.28 | $10,232.93 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $10,964.78 / $19,952.62
| Facility | | $4,265.80 | $10,964.78 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $5,754.40
| Facility | | $1,737.80 | $2,344.23 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Facility | AS | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,344.23
| Professional | | $1,995.26 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,348.96 / $2,238.72
| Facility | | $1,000.00 | $1,348.96 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $20,417.38 / $25,703.96
| Facility | | $4,677.35 | $20,417.38 | $25,703.96 |