- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $721.50 / $1,145.71 / $1,700.00
| Facility | | $721.50 | $1,145.71 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $797.09 / $887.27 / $966.69
| Facility | | $797.09 | $887.27 | $966.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $854.08 / $854.08 / $854.08
| Facility | | $854.08 | $854.08 | $854.08 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $84.56 / $84.56 / $84.56
| Facility | AS | $84.56 | $84.56 | $84.56 |
- 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 |