- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.78 / $5,462.34 / $10,651.00
| Facility | | $2,095.78 | $5,462.34 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,586.00 / $8,579.00 / $17,457.75
| Facility | | $4,586.00 | $8,579.00 | $17,457.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,644.20 / $2,137.46 / $2,795.14
| Facility | | $1,644.20 | $2,137.46 | $2,795.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.71 / $2,360.48 / $3,255.84
| Professional | | $1,790.71 | $2,360.48 | $3,255.84 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $44.28 / $44.28 / $44.28
| Professional | AS | $44.28 | $44.28 | $44.28 |
- 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 |