- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.73 / $103.73 / $1,400.00
| Facility | | $103.73 | $103.73 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.25 / $128.16 / $182.72
| Facility | | $113.25 | $128.16 | $182.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.82 / $120.82 / $120.82
| Facility | | $120.82 | $120.82 | $120.82 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $11.78 / $11.78 / $11.78
| Facility | AS | $11.78 | $11.78 | $11.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,248.39 / $10,248.39 / $10,248.39
| Facility | | $10,248.39 | $10,248.39 | $10,248.39 |