- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.34 / $1,151.26 / $3,050.00
| Facility | | $732.34 | $1,151.26 | $3,050.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.51 / $891.56 / $971.38
| Facility | | $784.51 | $891.56 | $971.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $840.68 / $840.68 / $840.68
| Facility | | $840.68 | $840.68 | $840.68 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $83.44 / $83.44 / $83.44
| Facility | AS | $83.44 | $83.44 | $83.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,439.00 / $4,439.00 / $4,439.00
| Facility | | $4,439.00 | $4,439.00 | $4,439.00 |