- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.31 / $3,965.56 / $3,965.56
| Facility | | $1,005.31 | $3,965.56 | $3,965.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $701.17 / $778.55 / $848.23
| Facility | | $701.17 | $778.55 | $848.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $755.12 / $755.12 / $755.12
| Facility | | $755.12 | $755.12 | $755.12 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $74.86 / $74.86 / $74.86
| Facility | AS | $74.86 | $74.86 | $74.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,881.55 / $20,881.55 / $20,881.55
| Facility | | $20,881.55 | $20,881.55 | $20,881.55 |