- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,635.92 / $2,600.00
| Facility | | $1,400.00 | $1,635.92 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,750.20 / $1,965.24 / $2,141.17
| Facility | | $1,750.20 | $1,965.24 | $2,141.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,869.23 / $1,869.23 / $1,869.23
| Facility | | $1,869.23 | $1,869.23 | $1,869.23 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $184.84 / $184.84 / $184.84
| Facility | AS | $184.84 | $184.84 | $184.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.70 / $1,172.70 / $1,172.70
| Facility | | $1,172.70 | $1,172.70 | $1,172.70 |