- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $9,120.11
| Facility | | $2,187.76 | $5,888.44 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,495.41 / $10,964.78
| Facility | | $2,137.96 | $5,495.41 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $7,244.36 / $9,772.37
| Facility | | $4,168.69 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,778.28 / $4,168.69
| Professional | | $1,412.54 | $1,778.28 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Professional | AS | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,311.31 / $10,964.78
| Facility | | $602.56 | $3,311.31 | $10,964.78 |