- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,648.30 / $2,790.62
| Facility | | $1,400.00 | $1,648.30 | $2,790.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,877.73 / $2,161.14 / $2,354.59
| Facility | | $1,877.73 | $2,161.14 | $2,354.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,011.86 / $2,011.86 / $2,011.86
| Facility | | $2,011.86 | $2,011.86 | $2,011.86 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $199.12 / $199.12 / $199.12
| Facility | AS | $199.12 | $199.12 | $199.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $17,949.13 / $17,949.13 / $17,949.13
| Facility | | $17,949.13 | $17,949.13 | $17,949.13 |