- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $897.60 / $1,401.23 / $10,985.00
| Facility | | $897.60 | $1,401.23 | $10,985.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,600.00 / $11,226.46 / $15,429.17
| Facility | | $4,600.00 | $11,226.46 | $15,429.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $829.13 / $1,077.86 / $1,243.70
| Facility | | $829.13 | $1,077.86 | $1,243.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $761.00 / $761.00 / $1,066.83
| Facility | | $761.00 | $761.00 | $1,066.83 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $104.84 / $104.84 / $104.84
| Facility | AS | $104.84 | $104.84 | $104.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $612.00 / $5,076.00 / $10,396.00
| Facility | | $612.00 | $5,076.00 | $10,396.00 |