- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.61 / $3,790.67 / $8,500.00
| Facility | | $719.61 | $3,790.67 | $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
- $883.20 / $1,383.68 / $2,122.60
| Facility | | $883.20 | $1,383.68 | $2,122.60 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $50.85 / $50.85 / $50.85
| Facility | AS | $50.85 | $50.85 | $50.85 |
- 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 |