- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $2,089.30
| Facility | | $1,412.54 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,630.27
| Facility | | $2,137.96 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,388.44 / $3,388.44
| Facility | | $34.67 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Facility | AS | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |