- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $2,341.64 / $6,067.00
| Facility | | $100.00 | $2,341.64 | $6,067.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,769.10 / $5,299.00 / $8,600.00
| Facility | | $4,769.10 | $5,299.00 | $8,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.78 / $2,862.32 / $2,962.50
| Facility | | $860.78 | $2,862.32 | $2,962.50 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $85.67 / $85.67 / $85.67
| Facility | AS | $85.67 | $85.67 | $85.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,155.00 / $11,155.00 / $11,155.00
| Facility | | $11,155.00 | $11,155.00 | $11,155.00 |