- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $752.38 / $3,477.00 / $8,000.00
| Facility | | $752.38 | $3,477.00 | $8,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,385.00 / $4,133.00 / $8,800.00
| Facility | | $2,385.00 | $4,133.00 | $8,800.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.46 / $956.86 / $1,272.50
| Facility | | $814.46 | $956.86 | $1,272.50 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $57.75 / $57.75 / $57.75
| Facility | AS | $57.75 | $57.75 | $57.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,832.00 / $3,764.00 / $7,934.00
| Facility | | $1,832.00 | $3,764.00 | $7,934.00 |