- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $5,370.32 / $7,413.10
| Facility | | $1,548.82 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,365.16 / $10,000.00
| Facility | | $1,513.56 | $4,365.16 | $10,000.00 |
- 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 / $1,023.29 / $1,905.46
| Professional | | $812.83 | $1,023.29 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $35.48 / $35.48 / $35.48
| Professional | AS | $35.48 | $35.48 | $35.48 |
- 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 |