- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,146.00 / $4,964.00 / $9,185.68
| Facility | | $4,146.00 | $4,964.00 | $9,185.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.35 / $1,250.04 / $2,234.61
| Professional | | $729.35 | $1,250.04 | $2,234.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,472.36 / $2,208.73 / $9,495.24
| Facility | | $1,472.36 | $2,208.73 | $9,495.24 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $757.42 / $757.42 / $757.42
| Facility | AS | $757.42 | $757.42 | $757.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,171.79 / $1,757.02 / $2,292.07
| Facility | | $1,171.79 | $1,757.02 | $2,292.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,341.00 / $7,091.00 / $10,320.00
| Facility | | $5,341.00 | $7,091.00 | $10,320.00 |