- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $4,365.16
| Facility | | $1,230.27 | $1,230.27 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $3,162.28
| Facility | | $1,621.81 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,754.23
| Professional | | $2,630.27 | $2,630.27 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,041.74 / $2,344.23
| Professional | | $1,584.89 | $2,041.74 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Professional | AS | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |