- 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
- $1,035.75 / $1,667.26 / $5,364.91
| Professional | | $1,035.75 | $1,667.26 | $5,364.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.37 / $2,369.48 / $3,928.95
| Facility | | $1,393.37 | $2,369.48 | $3,928.95 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $516.36 / $516.36 / $516.36
| Facility | AS | $516.36 | $516.36 | $516.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,967.00 / $2,482.52 / $3,182.79
| Facility | | $1,967.00 | $2,482.52 | $3,182.79 |
- 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 |