- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,331.21 / $9,859.00
| Facility | | $100.00 | $2,331.21 | $9,859.00 |
- 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
- $1,773.58 / $5,257.46 / $5,441.47
| Facility | | $1,773.58 | $5,257.46 | $5,441.47 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $175.11 / $175.11 / $175.11
| Facility | AS | $175.11 | $175.11 | $175.11 |
- 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 |