- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,635.88 / $1,635.88 / $1,635.88
| Facility | | $1,635.88 | $1,635.88 | $1,635.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,009.99 / $2,764.64 / $4,585.30
| Facility | | $2,009.99 | $2,764.64 | $4,585.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,583.85 / $3,869.77 / $5,545.79
| Facility | | $2,583.85 | $3,869.77 | $5,545.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,215.85 / $3,058.81 / $3,535.96
| Professional | | $2,215.85 | $3,058.81 | $3,535.96 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $672.65 / $672.65 / $672.65
| Professional | AS | $672.65 | $672.65 | $672.65 |
- 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 |