- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $1,698.24
| Facility | | $100.00 | $100.00 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $109.65 / $134.90
| Facility | | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $1,862.09
| Facility | | $173.78 | $173.78 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $17.38 / $17.38 / $17.38
| Facility | AS | $17.38 | $17.38 | $17.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,949.84
| Facility | | $1,737.80 | $1,737.80 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Facility | | $457.09 | $457.09 | $457.09 |