- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,463.36 / $7,119.04
| Facility | | $3,496.00 | $5,463.36 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.85 / $1,445.76 / $3,958.34
| Professional | | $892.85 | $1,445.76 | $3,958.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,244.82 / $2,160.44 / $10,463.00
| Facility | | $1,244.82 | $2,160.44 | $10,463.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,008.48 / $1,008.48 / $1,008.48
| Facility | AS | $1,008.48 | $1,008.48 | $1,008.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.00 / $2,551.71 / $3,508.23
| Facility | | $1,530.00 | $2,551.71 | $3,508.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $12,871.00 / $16,293.00
| Facility | | $1,770.00 | $12,871.00 | $16,293.00 |