- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,489.71 / $4,887.89
| Facility | | $100.00 | $1,489.71 | $4,887.89 |
- 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
- $714.12 / $1,751.69 / $1,812.99
| Facility | | $714.12 | $1,751.69 | $1,812.99 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $71.41 / $71.41 / $71.41
| Facility | AS | $71.41 | $71.41 | $71.41 |
- 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 |