- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.82 / $501.82 / $3,073.00
| Facility | | $501.82 | $501.82 | $3,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.15 / $844.06 / $1,279.01
| Facility | | $660.15 | $844.06 | $1,279.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $929.06 / $1,236.82 / $3,711.03
| Facility | | $929.06 | $1,236.82 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $595.07 / $817.60 / $983.29
| Professional | | $595.07 | $817.60 | $983.29 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $181.58 / $181.58 / $181.58
| Professional | AS | $181.58 | $181.58 | $181.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |