- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.78 / $6,028.00 / $10,651.00
| Facility | | $2,095.78 | $6,028.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,350.00 / $15,967.00 / $34,838.00
| Facility | | $9,350.00 | $15,967.00 | $34,838.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,028.60 / $5,028.60 / $15,840.40
| Facility | | $5,028.60 | $5,028.60 | $15,840.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $829.09 / $1,108.19 / $1,475.78
| Facility | | $829.09 | $1,108.19 | $1,475.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.97 / $1,190.28 / $1,641.76
| Professional | | $902.97 | $1,190.28 | $1,641.76 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $22.33 / $22.33 / $22.33
| Professional | AS | $22.33 | $22.33 | $22.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,251.00 / $11,924.00 / $19,712.00
| Facility | | $9,251.00 | $11,924.00 | $19,712.00 |