- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,523.32 / $4,466.59
| Facility | | $100.00 | $1,523.32 | $4,466.59 |
- 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
- $724.15 / $2,472.40 / $2,558.92
| Facility | | $724.15 | $2,472.40 | $2,558.92 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $72.42 / $72.42 / $72.42
| Facility | AS | $72.42 | $72.42 | $72.42 |
- 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 |