- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,025.60 / $9,772.37
| Facility | | $3,981.07 | $6,025.60 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,981.07 / $7,762.47
| Facility | | $1,698.24 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $776.25 / $1,513.56
| Facility | | $501.19 | $776.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $95.50 / $95.50 / $95.50
| Facility | AS | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,288.25
| Professional | | $870.96 | $870.96 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $741.31 / $1,230.27
| Facility | | $549.54 | $741.31 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $10,964.78 / $16,982.44
| Facility | | $1,995.26 | $10,964.78 | $16,982.44 |