- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $922.47 / $1,524.82 / $3,951.00
| Facility | | $922.47 | $1,524.82 | $3,951.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,053.16 / $1,180.84 / $1,286.56
| Facility | | $1,053.16 | $1,180.84 | $1,286.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.30 / $1,133.30 / $1,133.30
| Facility | | $1,133.30 | $1,133.30 | $1,133.30 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $112.26 / $112.26 / $112.26
| Facility | AS | $112.26 | $112.26 | $112.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,522.00 / $3,522.00 / $3,522.00
| Facility | | $3,522.00 | $3,522.00 | $3,522.00 |