- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.80 / $5,876.00 / $10,255.42
| Facility | | $3,890.80 | $5,876.00 | $10,255.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.16 / $2,259.17 / $6,282.78
| Professional | | $1,381.16 | $2,259.17 | $6,282.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,047.79 / $3,543.08 / $14,479.00
| Facility | | $2,047.79 | $3,543.08 | $14,479.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,887.52 / $1,887.52 / $1,887.52
| Facility | AS | $1,887.52 | $1,887.52 | $1,887.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,729.00 / $3,950.09 / $6,616.19
| Facility | | $2,729.00 | $3,950.09 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |