- 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
- $710.83 / $1,204.85 / $2,693.26
| Professional | | $710.83 | $1,204.85 | $2,693.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.36 / $1,885.67 / $11,139.12
| Facility | | $1,207.36 | $1,885.67 | $11,139.12 |
- 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
- $1,410.54 / $1,885.67 / $6,616.19
| Facility | | $1,410.54 | $1,885.67 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $6,588.00 / $10,320.00
| Facility | | $5,341.00 | $6,588.00 | $10,320.00 |