- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $5,623.41 / $14,125.38
| Facility | | $1,096.48 | $5,623.41 | $14,125.38 |
- 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
- $2,041.74 / $2,041.74 / $2,570.40
| Professional | | $2,041.74 | $2,041.74 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,290.87
| Facility | | $1,096.48 | $1,479.11 | $2,290.87 |
- 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
- $26,302.68 / $26,302.68 / $45,708.82
| Facility | | $26,302.68 | $26,302.68 | $45,708.82 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | AS | $2,630.27 | $2,630.27 | $2,630.27 |