- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,012.00 / $6,298.62 / $10,255.42
| Facility | | $5,012.00 | $6,298.62 | $10,255.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.44 / $1,881.10 / $4,979.05
| Professional | | $1,148.44 | $1,881.10 | $4,979.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,683.86 / $2,975.00 / $14,242.22
| Facility | | $1,683.86 | $2,975.00 | $14,242.22 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,887.52 / $1,887.52 / $1,887.52
| Facility | AS | $1,887.52 | $1,887.52 | $1,887.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,174.00 / $3,267.96 / $6,616.19
| Facility | | $2,174.00 | $3,267.96 | $6,616.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,220.00 / $9,259.00 / $14,242.22
| Facility | | $8,220.00 | $9,259.00 | $14,242.22 |