- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,737.80 / $2,951.21
| Facility | | $870.96 | $1,737.80 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $4,897.79
| Facility | | $3,090.30 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $114.82 / $114.82 / $114.82
| Facility | AS | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,248.07 / $8,511.38
| Facility | | $2,344.23 | $5,248.07 | $8,511.38 |