- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,795.58 / $1,795.58
| Facility | | $1,400.00 | $1,795.58 | $1,795.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.04 / $2,056.44 / $2,240.54
| Facility | | $1,784.04 | $2,056.44 | $2,240.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,921.18 / $1,921.18 / $1,921.18
| Facility | | $1,921.18 | $1,921.18 | $1,921.18 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $1,162.27 / $1,162.27 / $1,162.27
| Facility | 62 | $1,162.27 | $1,162.27 | $1,162.27 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $185.96 / $185.96 / $185.96
| Facility | AS | $185.96 | $185.96 | $185.96 |