- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $4,897.79 / $11,481.54
| Facility | | $831.76 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,888.44 / $13,489.63
| Facility | | $2,187.76 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,621.81 / $3,548.13
| Facility | | $831.76 | $1,621.81 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $83.18 / $83.18 / $83.18
| Facility | AS | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $10,000.00
| Facility | | $1,513.56 | $4,265.80 | $10,000.00 |