- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $4,466.84 / $10,000.00
| Facility | | $660.69 | $4,466.84 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,548.82
| Professional | | $1,122.02 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $891.25 / $1,412.54
| Facility | | $660.69 | $891.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $11,748.98 / $18,620.87
| Facility | | $5,011.87 | $11,748.98 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,952.62 / $19,952.62 / $33,884.42
| Facility | | $19,952.62 | $19,952.62 | $33,884.42 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | AS | $1,995.26 | $1,995.26 | $1,995.26 |