- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $2,454.71 / $6,456.54
| Facility | | $707.95 | $2,454.71 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $151.36 / $2,454.71
| Facility | | $109.65 | $151.36 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Facility | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,073.80 / $4,073.80
| Facility | | $1,995.26 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $83.18 / $83.18 / $83.18
| Facility | AS | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $812.83 / $2,511.89
| Facility | | $295.12 | $812.83 | $2,511.89 |