- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $7,413.10 / $15,488.17
| Facility | | $1,174.90 | $7,413.10 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,089.30
| Professional | | $1,513.56 | $1,513.56 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,174.90 / $1,819.70
| Facility | | $870.96 | $1,174.90 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $12,302.69 / $19,054.61
| Facility | | $4,168.69 | $12,302.69 | $19,054.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,623.41 / $5,623.41
| Facility | | $1,995.26 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | AS | $562.34 | $562.34 | $562.34 |