- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,331.21 / $3,783.50
| Facility | | $100.00 | $2,331.21 | $3,783.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,534.28 / $9,157.56 / $15,965.24
| Facility | | $3,534.28 | $9,157.56 | $15,965.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.82 / $1,271.82 / $1,271.82
| Facility | | $1,271.82 | $1,271.82 | $1,271.82 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $126.39 / $126.39 / $126.39
| Facility | AS | $126.39 | $126.39 | $126.39 |
- 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 |