- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $5,091.00 / $7,120.36
| Facility | | $4,146.00 | $5,091.00 | $7,120.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.96 / $1,530.80 / $3,575.12
| Professional | | $981.96 | $1,530.80 | $3,575.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.78 / $2,706.31 / $14,242.22
| Facility | | $1,632.78 | $2,706.31 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,460.76 / $2,460.76 / $2,460.76
| Facility | AS | $2,460.76 | $2,460.76 | $2,460.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,903.05 / $2,731.39 / $8,731.03
| Facility | | $1,903.05 | $2,731.39 | $8,731.03 |
- 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 |