- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,331.21 / $4,299.72
| Facility | | $100.00 | $2,331.21 | $4,299.72 |
- 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
- $944.77 / $2,862.32 / $2,962.50
| Facility | | $944.77 | $2,862.32 | $2,962.50 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $94.40 / $94.40 / $94.40
| Facility | AS | $94.40 | $94.40 | $94.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.00 / $11,155.00 / $11,155.00
| Facility | | $11,155.00 | $11,155.00 | $11,155.00 |