- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,019.95 / $10,471.29
| Facility | | $1,122.02 | $3,019.95 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,905.46
| Professional | | $1,412.54 | $1,412.54 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,621.81
| Facility | | $812.83 | $1,096.48 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,748.98 / $18,620.87
| Facility | | $5,011.87 | $11,748.98 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $33,884.42
| Facility | | $19,952.62 | $19,952.62 | $33,884.42 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | AS | $1,995.26 | $1,995.26 | $1,995.26 |