- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,098.47 / $1,400.00 / $1,700.00
| Facility | | $1,098.47 | $1,400.00 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,147.70 / $1,288.16 / $1,403.47
| Facility | | $1,147.70 | $1,288.16 | $1,403.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,231.67 / $1,231.67 / $1,231.67
| Facility | | $1,231.67 | $1,231.67 | $1,231.67 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $121.47 / $121.47 / $121.47
| Facility | AS | $121.47 | $121.47 | $121.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.00 / $765.00 / $765.00
| Facility | | $765.00 | $765.00 | $765.00 |