- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,504.58 / $2,600.00
| Facility | | $1,400.00 | $1,504.58 | $2,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,610.07 / $1,830.97 / $1,994.87
| Facility | | $1,610.07 | $1,830.97 | $1,994.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,720.92 / $1,720.92 / $1,720.92
| Facility | | $1,720.92 | $1,720.92 | $1,720.92 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $1,069.99 / $1,069.99 / $1,069.99
| Facility | 62 | $1,069.99 | $1,069.99 | $1,069.99 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $171.20 / $171.20 / $171.20
| Facility | AS | $171.20 | $171.20 | $171.20 |