- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,623.41 / $9,549.93
| Facility | | $3,019.95 | $5,623.41 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,548.13 / $19,952.62
| Facility | | $851.14 | $3,548.13 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $758.58 / $9,332.54
| Facility | | $398.11 | $758.58 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $7,244.36
| Professional | | $1,905.46 | $2,454.71 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $72.44 / $72.44 / $93.33
| Professional | AS | $72.44 | $72.44 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,511.89 / $10,000.00
| Facility | | $398.11 | $2,511.89 | $10,000.00 |