- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,035.25 / $2,693.50 / $7,615.50
| Facility | | $1,035.25 | $2,693.50 | $7,615.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $629.50 / $2,873.00 / $8,514.00
| Facility | | $629.50 | $2,873.00 | $8,514.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.59 / $1,115.59 / $1,115.59
| Facility | | $1,115.59 | $1,115.59 | $1,115.59 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $109.42 / $109.42 / $109.42
| Facility | AS | $109.42 | $109.42 | $109.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $1,221.00 / $3,685.00
| Facility | | $293.00 | $1,221.00 | $3,685.00 |