- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,185.03 / $1,185.03 / $1,400.00
| Facility | | $1,185.03 | $1,185.03 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.81 / $1,361.35 / $1,483.22
| Facility | | $1,181.81 | $1,361.35 | $1,483.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.21 / $1,271.21 / $1,271.21
| Facility | | $1,271.21 | $1,271.21 | $1,271.21 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $123.40 / $123.40 / $123.40
| Facility | AS | $123.40 | $123.40 | $123.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,148.13 / $22,148.13 / $22,148.13
| Facility | | $22,148.13 | $22,148.13 | $22,148.13 |