- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,170.47 / $5,045.00 / $7,268.00
| Facility | | $1,170.47 | $5,045.00 | $7,268.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,298.47 / $4,429.60 / $9,836.54
| Facility | | $1,298.47 | $4,429.60 | $9,836.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.00 / $550.00 / $550.00
| Facility | | $550.00 | $550.00 | $550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.34 / $1,623.09 / $4,291.50
| Professional | | $1,159.34 | $1,623.09 | $4,291.50 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $53.64 / $53.64 / $53.64
| Professional | AS | $53.64 | $53.64 | $53.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $607.00 / $3,629.00 / $10,000.00
| Facility | | $607.00 | $3,629.00 | $10,000.00 |