- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,370.32 / $9,549.93
| Facility | | $1,380.38 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,265.80 / $9,772.37
| Facility | | $1,230.27 | $4,265.80 | $9,772.37 |
- 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
- $954.99 / $1,174.90 / $2,511.89
| Professional | | $954.99 | $1,174.90 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | AS | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $8,912.51 / $19,498.45
| Facility | | $2,290.87 | $8,912.51 | $19,498.45 |