- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $728.10 / $1,235.25 / $1,600.00
| Facility | | $728.10 | $1,235.25 | $1,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.19 / $956.60 / $1,042.24
| Facility | | $850.19 | $956.60 | $1,042.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $910.85 / $910.85 / $910.85
| Facility | | $910.85 | $910.85 | $910.85 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $90.56 / $90.56 / $90.56
| Facility | AS | $90.56 | $90.56 | $90.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $19,334.30 / $19,334.30 / $19,334.30
| Facility | | $19,334.30 | $19,334.30 | $19,334.30 |