- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,551.00 / $5,503.00 / $10,651.00
| Facility | | $2,551.00 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,946.00 / $9,472.00 / $17,487.00
| Facility | | $5,946.00 | $9,472.00 | $17,487.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,368.33 / $1,681.42 / $2,298.79
| Facility | | $1,368.33 | $1,681.42 | $2,298.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.36 / $1,785.78 / $2,296.01
| Professional | | $1,252.36 | $1,785.78 | $2,296.01 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $31.54 / $31.54 / $31.54
| Professional | AS | $31.54 | $31.54 | $31.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,506.00 / $8,565.00 / $14,156.00
| Facility | | $2,506.00 | $8,565.00 | $14,156.00 |