- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,943.28 / $14,454.40
| Facility | | $5,754.40 | $7,943.28 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,882.50 / $25,118.86
| Facility | | $9,772.37 | $12,882.50 | $25,118.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,089.30 / $11,220.18
| Facility | | $1,174.90 | $2,089.30 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | AS | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,818.38 / $3,630.78
| Professional | | $2,630.27 | $2,818.38 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,570.88 / $13,803.84
| Facility | | $3,235.94 | $4,570.88 | $13,803.84 |