- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.00 / $7,090.00 / $11,611.47
| Facility | | $5,091.00 | $7,090.00 | $11,611.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.72 / $1,570.13 / $3,497.00
| Professional | | $902.72 | $1,570.13 | $3,497.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,532.47 / $2,390.76 / $12,342.67
| Facility | | $1,532.47 | $2,390.76 | $12,342.67 |
- 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
- $1,832.00 / $2,390.76 / $6,616.19
| Facility | | $1,832.00 | $2,390.76 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,221.00 / $11,139.12 / $18,346.22
| Facility | | $7,221.00 | $11,139.12 | $18,346.22 |