- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,393.30 / $5,503.00 / $10,651.00
| Facility | | $1,393.30 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,990.00 / $19,587.00 / $44,198.00
| Facility | | $10,990.00 | $19,587.00 | $44,198.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,904.40 / $12,904.40 / $40,649.56
| Facility | | $12,904.40 | $12,904.40 | $40,649.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,062.79 / $1,355.19 / $1,913.02
| Facility | | $1,062.79 | $1,355.19 | $1,913.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.50 / $1,525.79 / $2,104.54
| Professional | | $1,157.50 | $1,525.79 | $2,104.54 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $28.62 / $28.62 / $28.62
| Professional | AS | $28.62 | $28.62 | $28.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,146.00 / $13,967.00 / $20,534.00
| Facility | | $11,146.00 | $13,967.00 | $20,534.00 |