- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,937.00 / $5,503.00 / $10,651.00
| Facility | | $1,937.00 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,906.00 / $14,202.00 / $21,202.00
| Facility | | $5,906.00 | $14,202.00 | $21,202.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,795.31 / $6,795.31 / $21,405.59
| Facility | | $6,795.31 | $6,795.31 | $21,405.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $790.31 / $1,036.60 / $1,382.10
| Facility | | $790.31 | $1,036.60 | $1,382.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.73 / $1,134.59 / $1,564.96
| Professional | | $860.73 | $1,134.59 | $1,564.96 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $21.28 / $21.28 / $21.28
| Professional | AS | $21.28 | $21.28 | $21.28 |
- 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 |