- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $9,120.11 / $16,595.87
| Facility | | $3,019.95 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,760.83 / $12,589.25
| Facility | | $2,884.03 | $6,760.83 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,905.46 / $13,803.84
| Facility | | $891.25 | $1,905.46 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Facility | AS | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,570.40
| Professional | | $1,318.26 | $1,318.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,318.26 / $2,290.87
| Facility | | $562.34 | $1,318.26 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $13,182.57 / $23,988.33
| Facility | | $2,344.23 | $13,182.57 | $23,988.33 |