- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,388.44 / $7,413.10
| Facility | | $1,380.38 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,445.44 / $2,818.38
| Professional | | $758.58 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,819.70 / $7,413.10
| Facility | | $851.14 | $1,819.70 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | AS | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,187.76
| Professional | | $1,318.26 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,918.31 / $9,772.37
| Facility | | $3,630.78 | $6,918.31 | $9,772.37 |