- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,117.43 / $1,400.00 / $2,600.00
| Facility | | $1,117.43 | $1,400.00 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.96 / $1,461.24 / $1,592.04
| Facility | | $1,272.96 | $1,461.24 | $1,592.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,363.02 / $1,363.02 / $1,363.02
| Facility | | $1,363.02 | $1,363.02 | $1,363.02 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $135.37 / $135.37 / $135.37
| Facility | AS | $135.37 | $135.37 | $135.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,523.94 / $7,523.94 / $7,523.94
| Facility | | $7,523.94 | $7,523.94 | $7,523.94 |