- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.94 / $1,400.00 / $1,700.00
| Facility | | $1,005.94 | $1,400.00 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,111.00 / $1,236.58 / $1,347.27
| Facility | | $1,111.00 | $1,236.58 | $1,347.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.83 / $1,191.83 / $1,191.83
| Facility | | $1,191.83 | $1,191.83 | $1,191.83 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $118.18 / $118.18 / $118.18
| Facility | AS | $118.18 | $118.18 | $118.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,733.73 / $6,733.73 / $6,733.73
| Facility | | $6,733.73 | $6,733.73 | $6,733.73 |