- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $837.00 / $4,878.55 / $10,480.75
| Facility | | $837.00 | $4,878.55 | $10,480.75 |
- 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
- $6,629.13 / $6,629.13 / $20,882.13
| Facility | | $6,629.13 | $6,629.13 | $20,882.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.10 / $1,296.95 / $1,758.78
| Facility | | $977.10 | $1,296.95 | $1,758.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.17 / $1,402.77 / $1,934.86
| Professional | | $1,064.17 | $1,402.77 | $1,934.86 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $26.31 / $26.31 / $26.31
| Professional | AS | $26.31 | $26.31 | $26.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,284.00 / $14,321.00 / $23,683.00
| Facility | | $7,284.00 | $14,321.00 | $23,683.00 |