- 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
- $1,664.16 / $2,733.46 / $6,208.43
| Professional | | $1,664.16 | $2,733.46 | $6,208.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,430.42 / $3,742.85 / $5,418.47
| Facility | | $2,430.42 | $3,742.85 | $5,418.47 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $827.45 / $827.45 / $827.45
| Facility | AS | $827.45 | $827.45 | $827.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,101.41 / $3,978.14 / $5,061.41
| Facility | | $3,101.41 | $3,978.14 | $5,061.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,856.00
| Facility | | $2,126.00 | $5,847.00 | $7,856.00 |