- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $957.85 / $1,508.21 / $20,333.70
| Facility | | $957.85 | $1,508.21 | $20,333.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.95 / $1,168.00 / $1,272.55
| Facility | | $1,052.95 | $1,168.00 | $1,272.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.06 / $1,133.06 / $1,133.06
| Facility | | $1,133.06 | $1,133.06 | $1,133.06 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $112.33 / $112.33 / $112.33
| Facility | AS | $112.33 | $112.33 | $112.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,522.00 / $3,522.00 / $3,522.00
| Facility | | $3,522.00 | $3,522.00 | $3,522.00 |