- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $3,235.94 / $10,000.00
| Facility | | $724.44 | $3,235.94 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $9,332.54 / $16,218.10
| Facility | | $3,801.89 | $9,332.54 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $1,000.00 / $2,951.21
| Facility | | $323.59 | $1,000.00 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $63.10 / $63.10 / $63.10
| Facility | AS | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $1,202.26 / $3,715.35
| Facility | | $295.12 | $1,202.26 | $3,715.35 |