- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $5,370.32 / $7,413.10
| Facility | | $1,174.90 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,162.28 / $6,025.60
| Facility | | $1,230.27 | $3,162.28 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $1,202.26 / $2,511.89
| Facility | | $501.19 | $1,202.26 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | AS | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $954.99 / $3,890.45
| Professional | | $724.44 | $954.99 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $27.54 / $27.54 / $27.54
| Professional | AS | $27.54 | $27.54 | $27.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,168.69 / $6,918.31
| Facility | | $1,122.02 | $4,168.69 | $6,918.31 |