- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,370.32 / $7,943.28
| Facility | | $2,041.74 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,949.84 / $4,265.80
| Professional | | $1,258.93 | $1,949.84 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,235.94 / $7,244.36
| Facility | | $1,949.84 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | AS | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,235.94 / $4,570.88
| Professional | | $2,630.27 | $3,235.94 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |