- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $456.50 / $2,574.00 / $7,521.00
| Facility | | $456.50 | $2,574.00 | $7,521.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.00 / $4,120.00 / $8,836.00
| Facility | | $1,615.00 | $4,120.00 | $8,836.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.73 / $636.03 / $1,025.89
| Facility | | $508.73 | $636.03 | $1,025.89 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $26.40 / $26.40 / $26.40
| Facility | AS | $26.40 | $26.40 | $26.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.00 / $1,221.00 / $2,883.00
| Facility | | $376.00 | $1,221.00 | $2,883.00 |