- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $898.10 / $898.10 / $3,511.00
| Facility | | $898.10 | $898.10 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,158.17 / $1,490.01 / $2,147.31
| Facility | | $1,158.17 | $1,490.01 | $2,147.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,248.16 / $2,148.96 / $3,711.03
| Facility | | $1,248.16 | $2,148.96 | $3,711.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.62 / $1,398.06 / $1,703.29
| Professional | | $981.62 | $1,398.06 | $1,703.29 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $305.25 / $305.25 / $305.25
| Professional | AS | $305.25 | $305.25 | $305.25 |
- 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 |