- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,570.88 / $11,481.54
| Facility | | $1,819.70 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,128.61 / $15,135.61
| Facility | | $1,202.26 | $5,128.61 | $15,135.61 |
- 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
- $575.44 / $724.44 / $977.24
| Professional | | $575.44 | $724.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $42.66 / $42.66 / $42.66
| Professional | AS | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $10,964.78 / $45,708.82
| Facility | | $2,630.27 | $10,964.78 | $45,708.82 |