- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,374.41 / $6,298.62 / $34,437.50
| Facility | | $5,374.41 | $6,298.62 | $34,437.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,610.69 / $2,615.80 / $6,103.85
| Professional | | $1,610.69 | $2,615.80 | $6,103.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,297.17 / $3,810.02 / $9,346.00
| Facility | | $2,297.17 | $3,810.02 | $9,346.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $792.48 / $792.48 / $792.48
| Facility | AS | $792.48 | $792.48 | $792.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,582.88 / $3,810.02 / $5,401.87
| Facility | | $2,582.88 | $3,810.02 | $5,401.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,723.00 / $9,673.00 / $14,242.22
| Facility | | $4,723.00 | $9,673.00 | $14,242.22 |