- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $2,454.71 / $7,585.78
| Facility | | $758.58 | $2,454.71 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,606.93 / $10,964.78
| Facility | | $4,265.80 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $891.25 / $4,570.88
| Facility | | $575.44 | $891.25 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | AS | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,311.31 / $5,888.44
| Facility | | $891.25 | $3,311.31 | $5,888.44 |