- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,235.94 / $6,760.83
| Facility | | $1,380.38 | $3,235.94 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,412.54 / $2,691.53
| Professional | | $776.25 | $1,412.54 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,513.56 / $4,677.35
| Facility | | $812.83 | $1,513.56 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $389.05 / $389.05 / $389.05
| Facility | AS | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $2,238.72
| Professional | | $1,445.44 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,786.30 / $6,309.57
| Facility | | $2,511.89 | $4,786.30 | $6,309.57 |