- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,365.16 / $5,623.41
| Facility | | $1,412.54 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $3,981.07
| Facility | | $1,862.09 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,311.31 / $3,388.44
| Professional | | $3,162.28 | $3,311.31 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,570.40 / $3,019.95
| Professional | | $1,737.80 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Professional | AS | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |