- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,801.89 / $10,000.00
| Facility | | $891.25 | $3,801.89 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $11,481.54 / $28,840.32
| Facility | | $4,897.79 | $11,481.54 | $28,840.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $1,230.27 / $10,964.78
| Facility | | $457.09 | $1,230.27 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $72.44 / $72.44 / $72.44
| Facility | AS | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $9,120.11 / $20,892.96
| Facility | | $2,951.21 | $9,120.11 | $20,892.96 |