- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,981.09 / $2,981.09 / $5,292.52
| Facility | | $2,981.09 | $2,981.09 | $5,292.52 |
- 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
- $112.52 / $112.52 / $112.52
| Facility | AS | $112.52 | $112.52 | $112.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.47 / $1,253.26 / $1,683.84
| Professional | | $988.47 | $1,253.26 | $1,683.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.00 / $362.00 / $1,109.00
| Facility | | $303.00 | $362.00 | $1,109.00 |