- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,331.21 / $3,771.29
| Facility | | $100.00 | $2,331.21 | $3,771.29 |
- 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
- $1,235.10 / $1,235.10 / $1,235.10
| Facility | | $1,235.10 | $1,235.10 | $1,235.10 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $122.70 / $122.70 / $122.70
| Facility | AS | $122.70 | $122.70 | $122.70 |
- 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 |