- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,012.00 / $6,298.62 / $10,255.42
| Facility | | $5,012.00 | $6,298.62 | $10,255.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.56 / $1,047.89 / $1,945.68
| Professional | | $657.56 | $1,047.89 | $1,945.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.74 / $1,582.97 / $8,689.00
| Facility | | $1,092.74 | $1,582.97 | $8,689.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $329.26 / $329.26 / $329.26
| Facility | AS | $329.26 | $329.26 | $329.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.00 / $1,582.97 / $2,024.68
| Facility | | $1,261.00 | $1,582.97 | $2,024.68 |
- 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 |