- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,623.41 / $7,943.28
| Facility | | $1,445.44 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,754.23 / $6,025.60
| Facility | | $1,174.90 | $2,754.23 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,047.13 / $2,187.76
| Facility | | $1,000.00 | $1,047.13 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | AS | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $912.01 / $3,388.44
| Professional | | $645.65 | $912.01 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $24.55 / $24.55 / $24.55
| Professional | AS | $24.55 | $24.55 | $24.55 |
- 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 |