- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $3,125.96 / $9,859.00
| Facility | | $100.00 | $3,125.96 | $9,859.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,669.00 / $20,162.41 / $35,151.03
| Facility | | $3,669.00 | $20,162.41 | $35,151.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,125.46 / $2,125.46 / $2,125.46
| Facility | | $2,125.46 | $2,125.46 | $2,125.46 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $209.94 / $209.94 / $209.94
| Facility | AS | $209.94 | $209.94 | $209.94 |
- 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 |