- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,749.77 / $8,965.00
| Facility | | $100.00 | $1,749.77 | $8,965.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $449.96 / $1,139.75 / $1,669.86
| Facility | | $449.96 | $1,139.75 | $1,669.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,115.59 / $1,115.59 / $1,115.59
| Facility | | $1,115.59 | $1,115.59 | $1,115.59 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $109.42 / $109.42 / $109.42
| Facility | AS | $109.42 | $109.42 | $109.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,448.00 / $7,448.00 / $7,448.00
| Facility | | $7,448.00 | $7,448.00 | $7,448.00 |