- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $9,549.93 / $15,848.93
| Facility | | $6,025.60 | $9,549.93 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,589.25 / $24,547.09
| Facility | | $9,772.37 | $12,589.25 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.09 / $426.58 / $3,890.45
| Facility | | $229.09 | $426.58 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Facility | AS | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $588.84 / $776.25
| Professional | | $549.54 | $588.84 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $4,570.88
| Facility | | $1,096.48 | $1,548.82 | $4,570.88 |