- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,570.88 / $7,413.10
| Facility | | $1,819.70 | $4,570.88 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,265.80 / $12,022.64
| Facility | | $1,202.26 | $4,265.80 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $7,244.36 / $10,000.00
| Facility | | $5,011.87 | $7,244.36 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $912.01 / $2,454.71
| Professional | | $691.83 | $912.01 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $48.98 / $48.98 / $48.98
| Professional | 80 | $48.98 | $48.98 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $23.99 / $23.99 / $23.99
| Professional | AS | $23.99 | $23.99 | $23.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $9,120.11 / $19,952.62
| Facility | | $2,290.87 | $9,120.11 | $19,952.62 |