- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,432.08 / $6,546.16 / $6,546.16
| Facility | | $1,432.08 | $6,546.16 | $6,546.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $998.28 / $1,109.04 / $1,208.32
| Facility | | $998.28 | $1,109.04 | $1,208.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.22 / $1,067.22 / $1,067.22
| Facility | | $1,067.22 | $1,067.22 | $1,067.22 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $105.84 / $105.84 / $105.84
| Facility | AS | $105.84 | $105.84 | $105.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,109.97 / $4,109.97 / $4,109.97
| Facility | | $4,109.97 | $4,109.97 | $4,109.97 |