- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.77 / $1,400.00 / $3,050.00
| Facility | | $1,117.77 | $1,400.00 | $3,050.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.60 / $1,344.67 / $1,465.05
| Facility | | $1,200.60 | $1,344.67 | $1,465.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,282.30 / $1,282.30 / $1,282.30
| Facility | | $1,282.30 | $1,282.30 | $1,282.30 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $127.24 / $127.24 / $127.24
| Facility | AS | $127.24 | $127.24 | $127.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,330.29 / $17,330.29 / $17,330.29
| Facility | | $17,330.29 | $17,330.29 | $17,330.29 |