- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $949.52 / $1,400.00 / $3,050.00
| Facility | | $949.52 | $1,400.00 | $3,050.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,021.14 / $1,139.05 / $1,241.01
| Facility | | $1,021.14 | $1,139.05 | $1,241.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,091.96 / $1,091.96 / $1,091.96
| Facility | | $1,091.96 | $1,091.96 | $1,091.96 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $108.27 / $108.27 / $108.27
| Facility | AS | $108.27 | $108.27 | $108.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,796.02 / $16,796.02 / $28,660.41
| Facility | | $16,796.02 | $16,796.02 | $28,660.41 |