- 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
- $1,008.11 / $1,586.17 / $3,975.29
| Professional | | $1,008.11 | $1,586.17 | $3,975.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,473.29 / $2,380.00 / $3,396.00
| Facility | | $1,473.29 | $2,380.00 | $3,396.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $502.44 / $502.44 / $502.44
| Facility | AS | $502.44 | $502.44 | $502.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,933.29 / $2,415.56 / $3,138.03
| Facility | | $1,933.29 | $2,415.56 | $3,138.03 |
- 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 |