- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,273.70 / $8,521.52 / $12,097.76
| Facility | | $3,273.70 | $8,521.52 | $12,097.76 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $6,042.30 / $6,042.30 / $6,042.30
| Facility | AS | $6,042.30 | $6,042.30 | $6,042.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $686.68 / $686.68 / $863.00
| Facility | | $686.68 | $686.68 | $863.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $67.78 / $67.78 / $67.78
| Facility | AS | $67.78 | $67.78 | $67.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,046.74 / $8,673.70 / $16,063.90
| Facility | | $5,046.74 | $8,673.70 | $16,063.90 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $6,042.30 / $6,042.30 / $6,042.30
| Facility | AS | $6,042.30 | $6,042.30 | $6,042.30 |