- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $7,413.10 / $11,481.54
| Facility | | $1,288.25 | $7,413.10 | $11,481.54 |
- 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
- $1,698.24 / $1,698.24 / $2,290.87
| Professional | | $1,698.24 | $1,698.24 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $1,949.84
| Facility | | $977.24 | $1,288.25 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $14,791.08 / $22,908.68
| Facility | | $5,370.32 | $14,791.08 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,703.96 / $25,703.96 / $45,708.82
| Facility | | $25,703.96 | $25,703.96 | $45,708.82 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | AS | $2,570.40 | $2,570.40 | $2,570.40 |