- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $130.33 / $130.33 / $1,400.00
| Facility | | $130.33 | $130.33 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.40 / $149.53 / $162.91
| Facility | | $129.40 | $149.53 | $162.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.91 / $138.91 / $138.91
| Facility | | $138.91 | $138.91 | $138.91 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $83.65 / $83.65 / $83.65
| Facility | 62 | $83.65 | $83.65 | $83.65 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $13.38 / $13.38 / $13.38
| Facility | AS | $13.38 | $13.38 | $13.38 |