- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,715.35 / $9,549.93
| Facility | | $891.25 | $3,715.35 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,248.07 / $10,964.78
| Facility | | $2,089.30 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,659.59 / $4,265.80
| Facility | | $954.99 | $1,659.59 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | AS | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,168.69 / $9,549.93
| Facility | | $1,479.11 | $4,168.69 | $9,549.93 |