- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.86 / $1,395.86 / $1,400.00
| Facility | | $1,395.86 | $1,395.86 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,469.45 / $1,681.07 / $1,831.56
| Facility | | $1,469.45 | $1,681.07 | $1,831.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,576.22 / $1,576.22 / $1,576.22
| Facility | | $1,576.22 | $1,576.22 | $1,576.22 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $962.11 / $962.11 / $962.11
| Facility | 62 | $962.11 | $962.11 | $962.11 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $153.94 / $153.94 / $153.94
| Facility | AS | $153.94 | $153.94 | $153.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $765.00 / $765.00 / $765.00
| Facility | | $765.00 | $765.00 | $765.00 |