- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $4,677.35 / $7,943.28
| Facility | | $891.25 | $4,677.35 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,819.70 / $4,365.16
| Professional | | $1,000.00 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,290.87 / $22,387.21
| Facility | | $1,148.15 | $2,290.87 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | AS | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $2,884.03
| Professional | | $1,905.46 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $11,748.98 / $28,183.83
| Facility | | $4,677.35 | $11,748.98 | $28,183.83 |