- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.98 / $2,647.68 / $5,686.89
| Facility | | $0.98 | $2,647.68 | $5,686.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $629.00 / $2,957.55 / $3,837.49
| Facility | | $629.00 | $2,957.55 | $3,837.49 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $42.13 / $42.13 / $42.13
| Facility | AS | $42.13 | $42.13 | $42.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.31 / $473.77 / $656.50
| Professional | | $370.31 | $473.77 | $656.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,236.00 / $1,679.00 / $3,590.00
| Facility | | $1,236.00 | $1,679.00 | $3,590.00 |