- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,548.13 / $7,585.78
| Facility | | $1,995.26 | $3,548.13 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $2,238.72 / $4,786.30
| Facility | | $691.83 | $2,238.72 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,000.00 / $2,187.76
| Facility | | $512.86 | $1,000.00 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $812.83 / $2,137.96
| Professional | | $630.96 | $812.83 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $22.91 / $22.91 / $29.51
| Professional | AS | $22.91 | $22.91 | $29.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $3,235.94 / $6,606.93
| Facility | | $616.60 | $3,235.94 | $6,606.93 |