- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,306.59 / $1,306.59 / $3,550.00
| Facility | | $1,306.59 | $1,306.59 | $3,550.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,385.20 / $1,568.47 / $1,708.88
| Facility | | $1,385.20 | $1,568.47 | $1,708.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,484.12 / $1,484.12 / $1,484.12
| Facility | | $1,484.12 | $1,484.12 | $1,484.12 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $146.15 / $146.15 / $146.15
| Facility | AS | $146.15 | $146.15 | $146.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,526.90 / $10,526.90 / $16,139.13
| Facility | | $10,526.90 | $10,526.90 | $16,139.13 |