- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,292.09 / $6,770.90
| Facility | | $100.00 | $2,292.09 | $6,770.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,302.10 / $3,669.21 / $6,000.00
| Facility | | $3,302.10 | $3,669.21 | $6,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $759.22 / $5,257.46 / $5,441.47
| Facility | | $759.22 | $5,257.46 | $5,441.47 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $75.45 / $75.45 / $75.45
| Facility | AS | $75.45 | $75.45 | $75.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,949.00 / $9,949.00 / $9,949.00
| Facility | | $9,949.00 | $9,949.00 | $9,949.00 |