- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.02 / $1,007.02 / $6,575.00
| Facility | | $1,007.02 | $1,007.02 | $6,575.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,088.76 / $4,753.08 / $8,582.37
| Facility | | $2,088.76 | $4,753.08 | $8,582.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,449.73 / $3,475.81 / $8,361.52
| Facility | | $2,449.73 | $3,475.81 | $8,361.52 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $114.90 / $114.90 / $114.90
| Facility | AS | $114.90 | $114.90 | $114.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,227.02 / $3,177.72 / $6,583.88
| Facility | | $2,227.02 | $3,177.72 | $6,583.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,007.02 / $1,727.46 / $3,041.57
| Facility | | $1,007.02 | $1,727.46 | $3,041.57 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $260.31 / $260.31 / $260.31
| Facility | AS | $260.31 | $260.31 | $260.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,940.00 / $7,872.00 / $11,531.00
| Facility | | $3,940.00 | $7,872.00 | $11,531.00 |