- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,693.00 / $6,066.00 / $10,506.16
| Facility | | $4,693.00 | $6,066.00 | $10,506.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.38 / $1,561.63 / $3,248.12
| Professional | | $1,045.38 | $1,561.63 | $3,248.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.00 / $2,331.42 / $4,898.00
| Facility | | $1,321.00 | $2,331.42 | $4,898.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $515.76 / $515.76 / $515.76
| Facility | AS | $515.76 | $515.76 | $515.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,552.00 / $2,331.42 / $3,293.03
| Facility | | $1,552.00 | $2,331.42 | $3,293.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.00 / $5,847.00 / $7,856.00
| Facility | | $1,321.00 | $5,847.00 | $7,856.00 |