- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,548.13 / $10,000.00
| Facility | | $1,122.02 | $3,548.13 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $2,884.03
| Facility | | $1,348.96 | $1,905.46 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,570.40 / $2,570.40
| Professional | | $2,344.23 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $2,187.76
| Professional | | $1,318.26 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Professional | AS | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |