- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $911.97 / $1,398.08 / $1,400.00
| Facility | | $911.97 | $1,398.08 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.66 / $1,082.71 / $1,179.63
| Facility | | $950.66 | $1,082.71 | $1,179.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,021.03 / $1,021.03 / $1,021.03
| Facility | | $1,021.03 | $1,021.03 | $1,021.03 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $100.07 / $100.07 / $100.07
| Facility | AS | $100.07 | $100.07 | $100.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,421.00 / $8,421.00 / $8,421.00
| Facility | | $8,421.00 | $8,421.00 | $8,421.00 |