- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,630.78 / $9,772.37
| Facility | | $630.96 | $3,630.78 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $1,584.89
| Professional | | $426.58 | $630.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,079.46 / $14,454.40
| Facility | | $2,818.38 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $616.60 / $1,174.90
| Professional | | $380.19 | $616.60 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $1,584.89 / $4,365.16
| Facility | | $645.65 | $1,584.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $75.86 / $75.86 / $75.86
| Facility | AS | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $758.58 / $1,548.82
| Professional | | $478.63 | $758.58 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $10,000.00
| Facility | | $1,513.56 | $4,265.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $630.96 / $1,148.15
| Professional | | $407.38 | $630.96 | $1,148.15 |