- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,412.54
| Facility | | $1,122.02 | $1,122.02 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,479.11
| Facility | | $1,174.90 | $1,174.90 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $1,905.46 / $1,905.46
| Facility | | $34.67 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $190.55 / $190.55 / $190.55
| Facility | AS | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |