- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,981.36 / $7,981.36 / $7,981.36
| Facility | | $7,981.36 | $7,981.36 | $7,981.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $582.00 / $629.00 / $2,530.00
| Facility | | $582.00 | $629.00 | $2,530.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $200.73 / $200.73 / $200.73
| Facility | AS | $200.73 | $200.73 | $200.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.09 / $2,151.52 / $3,102.38
| Professional | | $1,745.09 | $2,151.52 | $3,102.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.00 / $362.00 / $1,109.00
| Facility | | $303.00 | $362.00 | $1,109.00 |