- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,541.55 / $1,541.55
| Facility | | $1,400.00 | $1,541.55 | $1,541.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,545.83 / $1,771.34 / $1,929.91
| Facility | | $1,545.83 | $1,771.34 | $1,929.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,664.40 / $1,664.40 / $1,664.40
| Facility | | $1,664.40 | $1,664.40 | $1,664.40 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $1,013.84 / $1,013.84 / $1,013.84
| Facility | 62 | $1,013.84 | $1,013.84 | $1,013.84 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $162.21 / $162.21 / $162.21
| Facility | AS | $162.21 | $162.21 | $162.21 |