- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,691.53 / $6,025.60
| Facility | | $891.25 | $2,691.53 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,025.60 / $8,511.38
| Facility | | $2,951.21 | $6,025.60 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $2,951.21 / $2,951.21
| Facility | | $549.54 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,137.96 / $2,454.71
| Facility | | $724.44 | $2,137.96 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | 22 | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | AS | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $3,162.28 / $8,511.38
| Facility | | $912.01 | $3,162.28 | $8,511.38 |