- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,370.32 / $7,413.10
| Facility | | $1,202.26 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,128.61 / $15,135.61
| Facility | | $1,737.80 | $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
- $977.24 / $1,258.93 / $1,621.81
| Professional | | $977.24 | $1,258.93 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $70.79 / $70.79 / $70.79
| Professional | AS | $70.79 | $70.79 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $13,803.84 / $45,708.82
| Facility | | $5,370.32 | $13,803.84 | $45,708.82 |