- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $789.42 / $1,228.84 / $1,700.00
| Facility | | $789.42 | $1,228.84 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.16 / $951.66 / $1,036.83
| Facility | | $854.16 | $951.66 | $1,036.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $913.96 / $913.96 / $913.96
| Facility | | $913.96 | $913.96 | $913.96 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $90.78 / $90.78 / $90.78
| Facility | AS | $90.78 | $90.78 | $90.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,701.39 / $11,701.39 / $11,701.39
| Facility | | $11,701.39 | $11,701.39 | $11,701.39 |