- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,863.11 / $2,886.35
| Facility | | $1,400.00 | $1,863.11 | $2,886.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,988.59 / $2,235.26 / $2,435.36
| Facility | | $1,988.59 | $2,235.26 | $2,435.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.46 / $2,125.46 / $2,125.46
| Facility | | $2,125.46 | $2,125.46 | $2,125.46 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $209.94 / $209.94 / $209.94
| Facility | AS | $209.94 | $209.94 | $209.94 |
- 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 |