- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $3,715.35 / $10,000.00
| Facility | | $954.99 | $3,715.35 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,888.44 / $13,489.63
| Facility | | $2,290.87 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,949.84 / $5,011.87
| Facility | | $1,174.90 | $1,949.84 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $117.49 / $117.49 / $117.49
| Facility | AS | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $12,302.69
| Facility | | $1,949.84 | $5,495.41 | $12,302.69 |