- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $882.92 / $1,372.22 / $2,300.00
| Facility | | $882.92 | $1,372.22 | $2,300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $951.89 / $1,062.70 / $1,157.81
| Facility | | $951.89 | $1,062.70 | $1,157.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.50 / $1,018.50 / $1,018.50
| Facility | | $1,018.50 | $1,018.50 | $1,018.50 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $101.30 / $101.30 / $101.30
| Facility | AS | $101.30 | $101.30 | $101.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,477.95 / $13,477.95 / $13,477.95
| Facility | | $13,477.95 | $13,477.95 | $13,477.95 |