- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,496.00 / $5,091.00 / $7,119.04
| Facility | | $3,496.00 | $5,091.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.75 / $936.13 / $2,020.87
| Professional | | $593.75 | $936.13 | $2,020.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.10 / $1,428.77 / $11,732.00
| Facility | | $891.10 | $1,428.77 | $11,732.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,279.44 / $1,279.44 / $1,279.44
| Facility | AS | $1,279.44 | $1,279.44 | $1,279.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $959.91 / $1,411.92 / $1,946.05
| Facility | | $959.91 | $1,411.92 | $1,946.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,770.00 / $7,487.00 / $11,732.00
| Facility | | $1,770.00 | $7,487.00 | $11,732.00 |