- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,138.15 / $1,138.15 / $2,600.00
| Facility | | $1,138.15 | $1,138.15 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,276.89 / $1,420.67 / $1,547.84
| Facility | | $1,276.89 | $1,420.67 | $1,547.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.13 / $1,366.13 / $1,366.13
| Facility | | $1,366.13 | $1,366.13 | $1,366.13 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $133.51 / $133.51 / $133.51
| Facility | AS | $133.51 | $133.51 | $133.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41,553.48 / $41,553.48 / $41,553.48
| Facility | | $41,553.48 | $41,553.48 | $41,553.48 |