- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $2,290.87
| Facility | | $812.83 | $812.83 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $870.96 / $1,071.52
| Facility | | $870.96 | $870.96 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $2,290.87
| Facility | | $1,412.54 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | AS | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $20,417.38
| Facility | | $3,548.13 | $3,548.13 | $20,417.38 |