- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $6,066.00 / $11,100.08
| Facility | | $4,277.00 | $6,066.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,636.37 / $2,651.44 / $7,349.36
| Professional | | $1,636.37 | $2,651.44 | $7,349.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,412.03 / $4,076.33 / $9,673.00
| Facility | | $2,412.03 | $4,076.33 | $9,673.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $812.47 / $812.47 / $812.47
| Facility | AS | $812.47 | $812.47 | $812.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,087.96 / $3,906.09 / $5,051.60
| Facility | | $3,087.96 | $3,906.09 | $5,051.60 |
- 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 |