- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.02 / $158.35 / $1,700.00
| Facility | | $101.02 | $158.35 | $1,700.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.91 / $122.64 / $133.61
| Facility | | $108.91 | $122.64 | $133.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.81 / $115.81 / $115.81
| Facility | | $115.81 | $115.81 | $115.81 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $11.30 / $11.30 / $11.30
| Facility | AS | $11.30 | $11.30 | $11.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,967.60 / $1,967.60 / $1,967.60
| Facility | | $1,967.60 | $1,967.60 | $1,967.60 |