- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $506.21 / $506.21 / $506.21
| Facility | | $506.21 | $506.21 | $506.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $612.41 / $832.97 / $1,325.01
| Facility | | $612.41 | $832.97 | $1,325.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.74 / $1,285.00 / $8,250.46
| Facility | | $933.74 | $1,285.00 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.14 / $851.25 / $1,001.40
| Professional | | $625.14 | $851.25 | $1,001.40 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $187.24 / $187.24 / $187.24
| Professional | AS | $187.24 | $187.24 | $187.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |