- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $2,187.76 / $4,265.80
| Facility | | $707.95 | $2,187.76 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $4,073.80 / $5,888.44
| Facility | | $2,137.96 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,912.51 / $8,912.51 / $45,708.82
| Facility | | $8,912.51 | $8,912.51 | $45,708.82 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $891.25 / $891.25 / $891.25
| Facility | AS | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,570.88 / $7,585.78
| Facility | | $2,754.23 | $4,570.88 | $7,585.78 |