- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $807.94 / $1,246.75 / $1,700.00
| Facility | | $807.94 | $1,246.75 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.73 / $965.52 / $1,051.95
| Facility | | $867.73 | $965.52 | $1,051.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $932.19 / $932.19 / $932.19
| Facility | | $932.19 | $932.19 | $932.19 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $92.87 / $92.87 / $92.87
| Facility | AS | $92.87 | $92.87 | $92.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,910.00 / $2,910.00 / $2,910.00
| Facility | | $2,910.00 | $2,910.00 | $2,910.00 |