- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,040.28 / $2,331.21
| Facility | | $100.00 | $1,040.28 | $2,331.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,497.60 / $4,516.99 / $7,874.90
| Facility | | $1,497.60 | $4,516.99 | $7,874.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.52 / $333.52 / $333.52
| Facility | | $333.52 | $333.52 | $333.52 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $32.72 / $32.72 / $32.72
| Facility | AS | $32.72 | $32.72 | $32.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,448.00 / $7,448.00 / $7,448.00
| Facility | | $7,448.00 | $7,448.00 | $7,448.00 |