- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,541.11 / $12,735.86 / $12,735.86
| Facility | | $1,541.11 | $12,735.86 | $12,735.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,871.39 / $2,553.08 / $4,119.88
| Facility | | $1,871.39 | $2,553.08 | $4,119.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,862.00 / $4,319.85 / $32,912.41
| Facility | | $2,862.00 | $4,319.85 | $32,912.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,008.27 / $2,714.86 / $3,193.75
| Professional | | $2,008.27 | $2,714.86 | $3,193.75 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $613.33 / $613.33 / $613.33
| Professional | AS | $613.33 | $613.33 | $613.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $36,780.10
| Facility | | $5,357.00 | $5,357.00 | $36,780.10 |