- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,370.32 / $9,549.93
| Facility | | $2,818.38 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,309.57 / $12,302.69
| Facility | | $2,238.72 | $6,309.57 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $5,011.87
| Professional | | $2,089.30 | $2,754.23 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $97.72 / $97.72 / $97.72
| Professional | AS | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $7,943.28
| Facility | | $602.56 | $3,235.94 | $7,943.28 |