- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $974.43 / $4,521.00 / $9,823.00
| Facility | | $974.43 | $4,521.00 | $9,823.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,091.00 / $10,117.00 / $19,207.43
| Facility | | $5,091.00 | $10,117.00 | $19,207.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.00 / $875.00 / $1,207.24
| Facility | | $875.00 | $875.00 | $1,207.24 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $85.60 / $85.60 / $85.60
| Facility | AS | $85.60 | $85.60 | $85.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,206.00 / $6,578.00 / $12,241.00
| Facility | | $3,206.00 | $6,578.00 | $12,241.00 |