- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $8,128.31 / $11,220.18
| Facility | | $1,318.26 | $8,128.31 | $11,220.18 |
- 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
- $1,445.44 / $1,445.44 / $1,995.26
| Professional | | $1,445.44 | $1,445.44 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,148.15 / $1,737.80
| Facility | | $851.14 | $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 / $50,118.72 / $50,118.72
| Facility | | $33,884.42 | $50,118.72 | $50,118.72 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | AS | $5,011.87 | $5,011.87 | $5,011.87 |