- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $2,537.26 / $2,537.26
| Facility | | $1,400.00 | $2,537.26 | $2,537.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,558.62 / $2,926.31 / $3,188.25
| Facility | | $2,558.62 | $2,926.31 | $3,188.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,745.68 / $2,745.68 / $2,745.68
| Facility | | $2,745.68 | $2,745.68 | $2,745.68 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $1,669.77 / $1,669.77 / $1,669.77
| Facility | 62 | $1,669.77 | $1,669.77 | $1,669.77 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $267.16 / $267.16 / $267.16
| Facility | AS | $267.16 | $267.16 | $267.16 |