- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.83 / $928.86 / $1,700.00
| Facility | | $603.83 | $928.86 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.84 / $628.84 / $783.73
| Facility | | $628.84 | $628.84 | $783.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $675.38 / $675.38 / $675.38
| Facility | | $675.38 | $675.38 | $675.38 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $65.84 / $65.84 / $65.84
| Facility | AS | $65.84 | $65.84 | $65.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,738.41 / $5,738.41 / $5,738.41
| Facility | | $5,738.41 | $5,738.41 | $5,738.41 |