- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,488.17 / $15,488.17 / $15,488.17
| Facility | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $3,388.44
| Facility | | $575.44 | $602.56 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Facility | AS | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $2,951.21
| Professional | | $1,584.89 | $2,089.30 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $416.87 / $1,230.27
| Facility | | $302.00 | $416.87 | $1,230.27 |