- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $768.55 / $1,199.94 / $1,400.00
| Facility | | $768.55 | $1,199.94 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $801.25 / $929.27 / $1,012.45
| Facility | | $801.25 | $929.27 | $1,012.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $858.84 / $858.84 / $858.84
| Facility | | $858.84 | $858.84 | $858.84 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $84.30 / $84.30 / $84.30
| Facility | AS | $84.30 | $84.30 | $84.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,700.31 / $12,700.31 / $12,700.31
| Facility | | $12,700.31 | $12,700.31 | $12,700.31 |