- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,844.88 / $4,295.68
| Facility | | $100.00 | $1,844.88 | $4,295.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,497.60 / $36,315.22 / $63,311.75
| Facility | | $1,497.60 | $36,315.22 | $63,311.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,262.82 / $1,262.82 / $1,262.82
| Facility | | $1,262.82 | $1,262.82 | $1,262.82 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $125.34 / $125.34 / $125.34
| Facility | AS | $125.34 | $125.34 | $125.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,399.00 / $12,399.00 / $12,399.00
| Facility | | $12,399.00 | $12,399.00 | $12,399.00 |