- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.97 / $1,018.97 / $1,400.00
| Facility | | $1,018.97 | $1,018.97 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,015.43 / $1,165.84 / $1,270.20
| Facility | | $1,015.43 | $1,165.84 | $1,270.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,092.83 / $1,092.83 / $1,092.83
| Facility | | $1,092.83 | $1,092.83 | $1,092.83 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $106.22 / $106.22 / $106.22
| Facility | AS | $106.22 | $106.22 | $106.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $15,155.78 / $15,155.78 / $15,155.78
| Facility | | $15,155.78 | $15,155.78 | $15,155.78 |