- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,588.75 / $3,684.00 / $7,838.38
| Facility | | $1,588.75 | $3,684.00 | $7,838.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,795.87 / $8,681.06 / $13,917.11
| Facility | | $3,795.87 | $8,681.06 | $13,917.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $680.00 / $870.49 / $1,814.27
| Facility | | $680.00 | $870.49 | $1,814.27 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $178.17 / $178.17 / $178.17
| Facility | AS | $178.17 | $178.17 | $178.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $718.00 / $2,575.00 / $7,326.50
| Facility | | $718.00 | $2,575.00 | $7,326.50 |