- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $687.36 / $687.36 / $2,600.00
| Facility | | $687.36 | $687.36 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $780.35 / $865.02 / $942.45
| Facility | | $780.35 | $865.02 | $942.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $842.26 / $842.26 / $842.26
| Facility | | $842.26 | $842.26 | $842.26 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $83.55 / $83.55 / $83.55
| Facility | AS | $83.55 | $83.55 | $83.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,546.14 / $4,546.14 / $4,546.14
| Facility | | $4,546.14 | $4,546.14 | $4,546.14 |