- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,659.60 / $9,859.00
| Facility | | $100.00 | $2,659.60 | $9,859.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,380.44 / $8,077.82 / $14,082.83
| Facility | | $3,380.44 | $8,077.82 | $14,082.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,802.76 / $1,802.76 / $1,802.76
| Facility | | $1,802.76 | $1,802.76 | $1,802.76 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $178.36 / $178.36 / $178.36
| Facility | AS | $178.36 | $178.36 | $178.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,565.00 / $9,565.00 / $9,565.00
| Facility | | $9,565.00 | $9,565.00 | $9,565.00 |