- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,563.83 / $1,563.83 / $1,563.83
| Facility | | $1,563.83 | $1,563.83 | $1,563.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,839.29 / $2,291.53 / $4,144.81
| Facility | | $1,839.29 | $2,291.53 | $4,144.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,360.34 / $3,794.09 / $4,900.28
| Facility | | $2,360.34 | $3,794.09 | $4,900.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,972.44 / $2,666.60 / $3,081.83
| Professional | | $1,972.44 | $2,666.60 | $3,081.83 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $589.26 / $589.26 / $589.26
| Professional | AS | $589.26 | $589.26 | $589.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |