- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.44 / $1,400.00 / $3,050.00
| Facility | | $1,274.44 | $1,400.00 | $3,050.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,367.17 / $1,563.10 / $1,703.01
| Facility | | $1,367.17 | $1,563.10 | $1,703.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,463.39 / $1,463.39 / $1,463.39
| Facility | | $1,463.39 | $1,463.39 | $1,463.39 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $908.75 / $908.75 / $908.75
| Facility | 62 | $908.75 | $908.75 | $908.75 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $145.40 / $145.40 / $145.40
| Facility | AS | $145.40 | $145.40 | $145.40 |