- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,238.75 / $3,133.00 / $8,734.00
| Facility | | $1,238.75 | $3,133.00 | $8,734.00 |
- 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
- $6,346.18 / $6,346.18 / $19,990.81
| Facility | | $6,346.18 | $6,346.18 | $19,990.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.10 / $1,025.59 / $1,338.74
| Facility | | $752.10 | $1,025.59 | $1,338.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.63 / $1,147.15 / $1,504.21
| Professional | | $949.63 | $1,147.15 | $1,504.21 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $20.66 / $20.66 / $20.66
| Professional | AS | $20.66 | $20.66 | $20.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,251.00 / $11,924.00 / $19,712.00
| Facility | | $9,251.00 | $11,924.00 | $19,712.00 |