- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,467.37 / $7,244.36
| Facility | | $891.25 | $3,467.37 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,479.11
| Facility | | $1,445.44 | $1,445.44 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,380.38
| Professional | | $870.96 | $870.96 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $741.31 / $1,174.90
| Facility | | $575.44 | $741.31 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $6,918.31 / $10,471.29
| Facility | | $1,659.59 | $6,918.31 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $28,840.32
| Facility | | $5,248.07 | $5,248.07 | $28,840.32 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Facility | AS | $524.81 | $524.81 | $524.81 |