- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,370.32 / $7,943.28
| Facility | | $1,905.46 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,370.32 / $11,220.18
| Facility | | $2,187.76 | $5,370.32 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,511.89 / $4,786.30
| Facility | | $1,995.26 | $2,511.89 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $199.53 / $199.53 / $199.53
| Facility | AS | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $6,456.54
| Professional | | $1,230.27 | $1,621.81 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $46.77 / $46.77 / $46.77
| Professional | AS | $46.77 | $46.77 | $46.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,623.41 / $8,511.38
| Facility | | $1,513.56 | $5,623.41 | $8,511.38 |