- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.56 / $6,028.00 / $10,651.00
| Facility | | $1,590.56 | $6,028.00 | $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
- $14,210.23 / $14,210.23 / $44,763.02
| Facility | | $14,210.23 | $14,210.23 | $44,763.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $745.14 / $953.78 / $1,251.83
| Facility | | $745.14 | $953.78 | $1,251.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.54 / $1,069.75 / $1,475.52
| Professional | | $811.54 | $1,069.75 | $1,475.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $20.07 / $20.07 / $20.07
| Professional | AS | $20.07 | $20.07 | $20.07 |
- 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 |