- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $7,119.04 / $11,668.15
| Facility | | $4,964.00 | $7,119.04 | $11,668.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.25 / $2,146.48 / $3,385.96
| Professional | | $1,202.25 | $2,146.48 | $3,385.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,279.05 / $3,452.86 / $13,476.00
| Facility | | $2,279.05 | $3,452.86 | $13,476.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $597.35 / $597.35 / $597.35
| Facility | AS | $597.35 | $597.35 | $597.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,933.84 / $2,871.88 / $3,779.34
| Facility | | $1,933.84 | $2,871.88 | $3,779.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,234.00 / $11,555.00 / $14,242.22
| Facility | | $7,234.00 | $11,555.00 | $14,242.22 |