- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,630.07 / $3,640.00 / $8,066.50
| Facility | | $1,630.07 | $3,640.00 | $8,066.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,929.96 / $7,897.54 / $12,746.56
| Facility | | $3,929.96 | $7,897.54 | $12,746.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.00 / $950.00 / $1,802.76
| Facility | | $895.00 | $950.00 | $1,802.76 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $178.36 / $178.36 / $178.36
| Facility | AS | $178.36 | $178.36 | $178.36 |
- 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 |