- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,171.91 / $1,400.00 / $2,600.00
| Facility | | $1,171.91 | $1,400.00 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.21 / $1,410.89 / $1,537.19
| Facility | | $1,260.21 | $1,410.89 | $1,537.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,346.11 / $1,346.11 / $1,346.11
| Facility | | $1,346.11 | $1,346.11 | $1,346.11 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $133.62 / $133.62 / $133.62
| Facility | AS | $133.62 | $133.62 | $133.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,398.60 / $7,398.60 / $7,398.60
| Facility | | $7,398.60 | $7,398.60 | $7,398.60 |