- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,582.40 / $3,940.00 / $7,602.00
| Facility | | $1,582.40 | $3,940.00 | $7,602.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,984.00 / $5,486.00 / $9,283.00
| Facility | | $2,984.00 | $5,486.00 | $9,283.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Facility | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,619.88 / $19,913.50 / $26,542.00
| Facility | | $4,619.88 | $19,913.50 | $26,542.00 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $210.47 / $1,887.52 / $1,887.52
| Facility | AS | $210.47 | $1,887.52 | $1,887.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,905.00 / $6,073.00 / $10,287.00
| Facility | | $2,905.00 | $6,073.00 | $10,287.00 |