- 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
- $1,000.17 / $1,609.88 / $3,328.73
| Professional | | $1,000.17 | $1,609.88 | $3,328.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,386.63 / $2,335.23 / $4,898.00
| Facility | | $1,386.63 | $2,335.23 | $4,898.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $494.71 / $494.71 / $494.71
| Facility | AS | $494.71 | $494.71 | $494.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,669.49 / $2,378.42 / $3,357.17
| Facility | | $1,669.49 | $2,378.42 | $3,357.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,966.00 / $6,110.41 / $7,407.10
| Facility | | $1,966.00 | $6,110.41 | $7,407.10 |