- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.14 / $426.14 / $3,073.00
| Facility | | $426.14 | $426.14 | $3,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $557.20 / $724.34 / $1,077.00
| Facility | | $557.20 | $724.34 | $1,077.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $793.12 / $1,055.75 / $10,430.85
| Facility | | $793.12 | $1,055.75 | $10,430.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.58 / $693.72 / $826.74
| Professional | | $504.58 | $693.72 | $826.74 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $153.40 / $153.40 / $153.40
| Professional | AS | $153.40 | $153.40 | $153.40 |
- 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 |