- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,418.62 / $1,418.62
| Facility | | $1,400.00 | $1,418.62 | $1,418.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,610.80 / $1,872.40 / $2,040.00
| Facility | | $1,610.80 | $1,872.40 | $2,040.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,725.96 / $1,725.96 / $1,725.96
| Facility | | $1,725.96 | $1,725.96 | $1,725.96 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $171.54 / $171.54 / $171.54
| Facility | AS | $171.54 | $171.54 | $171.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,450.15 / $16,450.15 / $16,450.15
| Facility | | $16,450.15 | $16,450.15 | $16,450.15 |