- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $601.38 / $3,650.50 / $8,475.50
| Facility | | $601.38 | $3,650.50 | $8,475.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,396.24 / $4,608.26 / $8,213.69
| Facility | | $2,396.24 | $4,608.26 | $8,213.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.70 / $788.70 / $908.00
| Facility | | $788.70 | $788.70 | $908.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $55.92 / $55.92 / $55.92
| Facility | AS | $55.92 | $55.92 | $55.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.00 / $3,325.00 / $8,198.00
| Facility | | $1,292.00 | $3,325.00 | $8,198.00 |