- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $982.40 / $982.40 / $983.41
| Facility | | $982.40 | $982.40 | $983.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,188.20 / $1,581.65 / $2,610.27
| Facility | | $1,188.20 | $1,581.65 | $2,610.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,775.37 / $2,639.69 / $8,250.46
| Facility | | $1,775.37 | $2,639.69 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.96 / $1,665.65 / $1,959.46
| Professional | | $1,224.96 | $1,665.65 | $1,959.46 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $364.32 / $364.32 / $364.32
| Professional | AS | $364.32 | $364.32 | $364.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |