- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $7,943.28 / $12,589.25
| Facility | | $1,949.84 | $7,943.28 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,456.54 / $13,182.57
| Facility | | $5,248.07 | $6,456.54 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,290.87 / $12,589.25
| Facility | | $758.58 | $2,290.87 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | AS | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,778.28 / $2,398.83
| Professional | | $1,698.24 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,606.93 / $8,912.51
| Facility | | $4,677.35 | $6,606.93 | $8,912.51 |