- 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
- $9,350.00 / $15,967.00 / $33,678.00
| Facility | | $9,350.00 | $15,967.00 | $33,678.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,246.46 / $2,973.03 / $4,043.65
| Facility | | $2,246.46 | $2,973.03 | $4,043.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.08 / $3,290.28 / $4,538.32
| Professional | | $2,496.08 | $3,290.28 | $4,538.32 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $61.72 / $61.72 / $61.72
| Professional | AS | $61.72 | $61.72 | $61.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,640.00 / $8,535.00 / $12,740.00
| Facility | | $2,640.00 | $8,535.00 | $12,740.00 |