- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,714.36 / $1,714.36 / $1,714.36
| Facility | | $1,714.36 | $1,714.36 | $1,714.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,897.27 / $4,855.59
| Facility | | $2,000.00 | $2,897.27 | $4,855.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,735.97 / $4,434.85 / $5,865.94
| Facility | | $2,735.97 | $4,434.85 | $5,865.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,402.80 / $3,253.18 / $3,751.37
| Professional | | $2,402.80 | $3,253.18 | $3,751.37 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $714.99 / $714.99 / $714.99
| Professional | AS | $714.99 | $714.99 | $714.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |