- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,801.89 / $12,589.25
| Facility | | $1,737.80 | $3,801.89 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $3,715.35
| Facility | | $1,445.44 | $1,905.46 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $331.13 / $1,778.28
| Facility | | $181.97 | $331.13 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | AS | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $467.74 / $660.69
| Professional | | $457.09 | $467.74 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $4,570.88
| Facility | | $1,096.48 | $1,548.82 | $4,570.88 |