- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $3,890.45 / $10,715.19
| Facility | | $630.96 | $3,890.45 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,079.46 / $14,454.40
| Facility | | $2,398.83 | $7,079.46 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,548.82 / $4,466.84
| Facility | | $630.96 | $1,548.82 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $72.44 / $72.44 / $72.44
| Facility | AS | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $10,000.00
| Facility | | $1,513.56 | $4,265.80 | $10,000.00 |