- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,445.44 / $2,398.83
| Facility | | $776.25 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,890.45
| Facility | | $2,398.83 | $2,884.03 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Facility | AS | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,884.03 / $4,073.80
| Facility | | $812.83 | $2,884.03 | $4,073.80 |