- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $560.16 / $560.16 / $3,073.00
| Facility | | $560.16 | $560.16 | $3,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $701.72 / $921.40 / $1,450.83
| Facility | | $701.72 | $921.40 | $1,450.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $953.00 / $1,383.11 / $8,250.46
| Facility | | $953.00 | $1,383.11 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.77 / $947.38 / $1,131.43
| Professional | | $644.77 | $947.38 | $1,131.43 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $203.97 / $203.97 / $203.97
| Professional | AS | $203.97 | $203.97 | $203.97 |
- 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 |