- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,147.45 / $1,147.45 / $1,400.00
| Facility | | $1,147.45 | $1,147.45 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,283.50 / $1,442.03 / $1,571.12
| Facility | | $1,283.50 | $1,442.03 | $1,571.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.51 / $1,373.51 / $1,373.51
| Facility | | $1,373.51 | $1,373.51 | $1,373.51 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $134.81 / $134.81 / $134.81
| Facility | AS | $134.81 | $134.81 | $134.81 |
- Facility/Professional
- Facility
- Modifier
- 50
- Low / Median / High Price
- $5,598.96 / $5,598.96 / $5,598.96
| Facility | 50 | $5,598.96 | $5,598.96 | $5,598.96 |