- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $367.22 / $572.74 / $1,400.00
| Facility | | $367.22 | $572.74 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $384.72 / $443.54 / $483.25
| Facility | | $384.72 | $443.54 | $483.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $410.86 / $410.86 / $410.86
| Facility | | $410.86 | $410.86 | $410.86 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $251.89 / $251.89 / $251.89
| Facility | 62 | $251.89 | $251.89 | $251.89 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $40.29 / $40.29 / $40.29
| Facility | AS | $40.29 | $40.29 | $40.29 |