- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,011.87 / $12,589.25
| Facility | | $2,344.23 | $5,011.87 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,244.36 / $14,125.38
| Facility | | $5,495.41 | $7,244.36 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $1,288.25 / $4,570.88
| Facility | | $758.58 | $1,288.25 | $4,570.88 |
- 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
- $1,584.89 / $1,862.09 / $2,570.40
| Professional | | $1,584.89 | $1,862.09 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,495.41 / $8,912.51
| Facility | | $3,467.37 | $5,495.41 | $8,912.51 |