- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,296.29 / $1,296.29 / $1,400.00
| Facility | | $1,296.29 | $1,296.29 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,285.40 / $1,481.34 / $1,613.94
| Facility | | $1,285.40 | $1,481.34 | $1,613.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,381.32 / $1,381.32 / $1,381.32
| Facility | | $1,381.32 | $1,381.32 | $1,381.32 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $133.77 / $133.77 / $133.77
| Facility | AS | $133.77 | $133.77 | $133.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.00 / $765.00 / $765.00
| Facility | | $765.00 | $765.00 | $765.00 |