- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,623.41 / $10,964.78
| Facility | | $1,584.89 | $5,623.41 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,495.41 / $10,964.78
| Facility | | $2,137.96 | $5,495.41 | $10,964.78 |
- 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
- $812.83 / $1,000.00 / $2,137.96
| Professional | | $812.83 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $25.70 / $25.70 / $25.70
| Professional | AS | $25.70 | $25.70 | $25.70 |
- 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 |