- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $8,912.51 / $16,595.87
| Facility | | $3,467.37 | $8,912.51 | $16,595.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $10,000.00 / $18,620.87
| Facility | | $4,265.80 | $10,000.00 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $2,187.76
| Facility | | $812.83 | $1,258.93 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Facility | AS | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,951.21
| Professional | | $2,089.30 | $2,089.30 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,698.24 / $2,818.38
| Facility | | $1,258.93 | $1,698.24 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $17,378.01 / $26,302.68
| Facility | | $3,630.78 | $17,378.01 | $26,302.68 |