- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,943.28 / $13,489.63
| Facility | | $4,265.80 | $7,943.28 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,918.31 / $13,489.63
| Facility | | $5,248.07 | $6,918.31 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $14,454.40
| Facility | | $14,454.40 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,778.28 / $19,054.61
| Facility | | $891.25 | $1,778.28 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $288.40 / $4,570.88 / $4,570.88
| Facility | AS | $288.40 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $3,467.37
| Professional | | $2,187.76 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14,454.40 / $14,454.40 / $14,454.40
| Facility | | $14,454.40 | $14,454.40 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $8,912.51 / $16,982.44
| Facility | | $4,786.30 | $8,912.51 | $16,982.44 |