- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $2,290.87
| Facility | | $758.58 | $758.58 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,000.00
| Facility | | $812.83 | $812.83 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,290.87
| Facility | | $1,318.26 | $1,318.26 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Facility | AS | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $20,417.38
| Facility | | $2,884.03 | $2,884.03 | $20,417.38 |