- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,120.62 / $7,119.04 / $11,432.54
| Facility | | $4,120.62 | $7,119.04 | $11,432.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,375.86 / $2,347.17 / $4,377.57
| Professional | | $1,375.86 | $2,347.17 | $4,377.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,190.23 / $3,833.77 / $22,189.40
| Facility | | $2,190.23 | $3,833.77 | $22,189.40 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,105.03 / $2,105.03 / $2,105.03
| Facility | AS | $2,105.03 | $2,105.03 | $2,105.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,316.42 / $3,265.31 / $4,535.28
| Facility | | $2,316.42 | $3,265.31 | $4,535.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,346.00 / $14,242.22
| Facility | | $8,220.00 | $9,346.00 | $14,242.22 |