- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.30 / $220.30 / $1,400.00
| Facility | | $220.30 | $220.30 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.50 / $310.58 / $381.98
| Facility | | $231.50 | $310.58 | $381.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.14 / $263.14 / $263.14
| Facility | | $263.14 | $263.14 | $263.14 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $25.84 / $25.84 / $25.84
| Facility | AS | $25.84 | $25.84 | $25.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,308.29 / $10,308.29 / $10,308.29
| Facility | | $10,308.29 | $10,308.29 | $10,308.29 |