- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,737.80 / $3,981.07
| Facility | | $891.25 | $1,737.80 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,630.78 / $4,897.79
| Facility | | $2,951.21 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $95.50 / $95.50 / $95.50
| Facility | AS | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $5,128.61
| Facility | | $1,122.02 | $3,630.78 | $5,128.61 |