- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,412.54
| Facility | | $1,202.26 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,737.80
| Facility | | $1,380.38 | $1,380.38 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $2,187.76 / $2,187.76
| Facility | | $34.67 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Facility | AS | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |