- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $811.25 / $1,235.59 / $3,550.00
| Facility | | $811.25 | $1,235.59 | $3,550.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.91 / $956.88 / $1,042.54
| Facility | | $868.91 | $956.88 | $1,042.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $946.59 / $946.59 / $946.59
| Facility | | $946.59 | $946.59 | $946.59 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $94.66 / $94.66 / $94.66
| Facility | AS | $94.66 | $94.66 | $94.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,684.75 / $11,684.75 / $38,628.08
| Facility | | $11,684.75 | $11,684.75 | $38,628.08 |