- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,370.32 / $9,549.93
| Facility | | $1,513.56 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,495.41 / $10,964.78
| Facility | | $2,137.96 | $5,495.41 | $10,964.78 |
- 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
- $933.25 / $1,174.90 / $2,398.83
| Professional | | $933.25 | $1,174.90 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $28.84 / $28.84 / $28.84
| Professional | AS | $28.84 | $28.84 | $28.84 |
- 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 |