- 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
- $1,737.80 / $4,897.79 / $10,232.93
| Facility | | $1,737.80 | $4,897.79 | $10,232.93 |
- 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 / $977.24 / $2,290.87
| Professional | | $794.33 | $977.24 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $26.92 / $26.92 / $26.92
| Professional | AS | $26.92 | $26.92 | $26.92 |
- 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 |