- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.24 / $1,400.00 / $2,600.00
| Facility | | $1,185.24 | $1,400.00 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,269.63 / $1,420.87 / $1,548.07
| Facility | | $1,269.63 | $1,420.87 | $1,548.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.64 / $1,357.64 / $1,357.64
| Facility | | $1,357.64 | $1,357.64 | $1,357.64 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $134.59 / $134.59 / $134.59
| Facility | AS | $134.59 | $134.59 | $134.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,421.00 / $8,421.00 / $8,421.00
| Facility | | $8,421.00 | $8,421.00 | $8,421.00 |