- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,678.80 / $3,635.83
| Facility | | $100.00 | $2,678.80 | $3,635.83 |
- 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
- $1,427.58 / $2,000.36 / $2,070.38
| Facility | | $1,427.58 | $2,000.36 | $2,070.38 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $142.76 / $142.76 / $142.76
| Facility | AS | $142.76 | $142.76 | $142.76 |
- 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 |