- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $5,370.32 / $7,943.28
| Facility | | $1,548.82 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $12,022.64
| Facility | | $1,513.56 | $4,265.80 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,318.26 / $13,803.84
| Facility | | $1,202.26 | $1,318.26 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Facility | AS | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $4,265.80
| Professional | | $812.83 | $1,202.26 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $30.90 / $30.90 / $30.90
| Professional | AS | $30.90 | $30.90 | $30.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $7,762.47 / $17,378.01
| Facility | | $1,995.26 | $7,762.47 | $17,378.01 |