- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,995.26 / $1,995.26
| Facility | | $1,412.54 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,818.38
| Facility | | $2,238.72 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,630.78 / $3,630.78
| Facility | | $34.67 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Facility | AS | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |