- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,445.44 / $2,238.72
| Facility | | $794.33 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $3,801.89
| Facility | | $1,698.24 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $870.96
| Facility | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $87.10 / $87.10 / $87.10
| Facility | AS | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $5,128.61
| Facility | | $1,122.02 | $3,630.78 | $5,128.61 |