- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $1,412.54
| Facility | | $1,258.93 | $1,258.93 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,584.89
| Facility | | $1,288.25 | $1,288.25 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $2,089.30 / $2,089.30
| Facility | | $34.67 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $208.93 / $208.93 / $208.93
| Facility | AS | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |