- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $12,882.50 / $21,877.62
| Facility | | $954.99 | $12,882.50 | $21,877.62 |
- 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
- $1,479.11 / $1,479.11 / $2,041.74
| Professional | | $1,479.11 | $1,479.11 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,148.15 / $1,737.80
| Facility | | $870.96 | $1,148.15 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $14,791.08 / $22,908.68
| Facility | | $6,025.60 | $14,791.08 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33,884.42 / $48,977.88 / $48,977.88
| Facility | | $33,884.42 | $48,977.88 | $48,977.88 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | AS | $4,897.79 | $4,897.79 | $4,897.79 |