- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,091.00 / $7,119.04
| Facility | | $3,496.00 | $5,091.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $720.79 / $1,180.64 / $2,720.78
| Professional | | $720.79 | $1,180.64 | $2,720.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.53 / $1,907.16 / $12,342.67
| Facility | | $1,179.53 | $1,907.16 | $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
- $1,427.33 / $1,907.16 / $6,616.19
| Facility | | $1,427.33 | $1,907.16 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,354.00 / $8,868.00 / $12,342.67
| Facility | | $6,354.00 | $8,868.00 | $12,342.67 |