- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $551.72 / $3,152.86 / $9,872.00
| Facility | | $551.72 | $3,152.86 | $9,872.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,434.00 / $5,126.00 / $9,729.00
| Facility | | $3,434.00 | $5,126.00 | $9,729.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,324.79 / $1,324.79 / $4,173.14
| Facility | | $1,324.79 | $1,324.79 | $4,173.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $551.72 / $721.44 / $932.27
| Facility | | $551.72 | $721.44 | $932.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.02 / $835.94 / $1,114.58
| Professional | | $613.02 | $835.94 | $1,114.58 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $15.16 / $15.16 / $15.16
| Professional | AS | $15.16 | $15.16 | $15.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,852.00 / $6,118.00 / $11,599.00
| Facility | | $2,852.00 | $6,118.00 | $11,599.00 |