- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $757.30 / $4,102.72 / $7,695.00
| Facility | | $757.30 | $4,102.72 | $7,695.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.00 / $5,196.00 / $10,517.23
| Facility | | $3,248.00 | $5,196.00 | $10,517.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $843.00 / $1,264.58 / $1,909.39
| Facility | | $843.00 | $1,264.58 | $1,909.39 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $60.88 / $60.88 / $60.88
| Facility | AS | $60.88 | $60.88 | $60.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.00 / $3,764.00 / $7,934.00
| Facility | | $1,832.00 | $3,764.00 | $7,934.00 |