- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $914.83 / $1,400.00 / $2,300.00
| Facility | | $914.83 | $1,400.00 | $2,300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.03 / $1,103.57 / $1,202.35
| Facility | | $988.03 | $1,103.57 | $1,202.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,056.44 / $1,056.44 / $1,056.44
| Facility | | $1,056.44 | $1,056.44 | $1,056.44 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $104.91 / $104.91 / $104.91
| Facility | AS | $104.91 | $104.91 | $104.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,563.78 / $17,563.78 / $17,563.78
| Facility | | $17,563.78 | $17,563.78 | $17,563.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36,074.25 / $36,074.25 / $36,074.25
| Facility | | $36,074.25 | $36,074.25 | $36,074.25 |