- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $5,370.32 / $7,585.78
| Facility | | $912.01 | $5,370.32 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,090.30 / $6,025.60
| Facility | | $1,230.27 | $3,090.30 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,202.26 / $2,187.76
| Facility | | $912.01 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $91.20 / $91.20 / $91.20
| Facility | AS | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $2,951.21
| Professional | | $575.44 | $724.44 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $20.89 / $20.89 / $20.89
| Professional | AS | $20.89 | $20.89 | $20.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,168.69 / $6,918.31
| Facility | | $1,122.02 | $4,168.69 | $6,918.31 |