- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,013.96 / $1,400.00 / $2,300.00
| Facility | | $1,013.96 | $1,400.00 | $2,300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,077.24 / $1,204.24 / $1,312.04
| Facility | | $1,077.24 | $1,204.24 | $1,312.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,154.44 / $1,154.44 / $1,154.44
| Facility | | $1,154.44 | $1,154.44 | $1,154.44 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $114.57 / $114.57 / $114.57
| Facility | AS | $114.57 | $114.57 | $114.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27,569.16 / $27,569.16 / $27,569.16
| Facility | | $27,569.16 | $27,569.16 | $27,569.16 |