- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $1,584.89
| Facility | | $691.83 | $691.83 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $1,000.00
| Facility | | $812.83 | $812.83 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,659.59
| Facility | | $1,318.26 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Facility | AS | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $5,495.41
| Facility | | $2,454.71 | $2,454.71 | $5,495.41 |