- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $5,370.32 / $7,585.78
| Facility | | $1,122.02 | $5,370.32 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,890.45 / $11,220.18
| Facility | | $1,513.56 | $3,890.45 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $6,309.57
| Facility | | $1,096.48 | $1,202.26 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $109.65 / $109.65 / $109.65
| Facility | AS | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $3,630.78
| Professional | | $691.83 | $1,000.00 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $25.70 / $25.70 / $25.70
| Professional | AS | $25.70 | $25.70 | $25.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $7,413.10 / $17,378.01
| Facility | | $1,995.26 | $7,413.10 | $17,378.01 |