- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $869.37 / $4,195.00 / $8,500.00
| Facility | | $869.37 | $4,195.00 | $8,500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.00 / $5,196.00 / $11,136.00
| Facility | | $3,248.00 | $5,196.00 | $11,136.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $931.72 / $1,574.05 / $2,172.58
| Facility | | $931.72 | $1,574.05 | $2,172.58 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $66.06 / $66.06 / $66.06
| Facility | AS | $66.06 | $66.06 | $66.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $5,111.00 / $9,202.00
| Facility | | $2,200.00 | $5,111.00 | $9,202.00 |