- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,888.44 / $9,549.93
| Facility | | $4,365.16 | $5,888.44 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,265.80 / $8,709.64
| Facility | | $1,737.80 | $4,265.80 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $954.99 / $4,365.16
| Professional | | $794.33 | $954.99 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $25.12 / $25.12 / $25.12
| Professional | AS | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $7,943.28
| Facility | | $602.56 | $3,235.94 | $7,943.28 |