- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $3,194.04 / $4,870.10
| Facility | | $1,400.00 | $3,194.04 | $4,870.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,304.59 / $3,771.55 / $4,109.16
| Facility | | $3,304.59 | $3,771.55 | $4,109.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,543.61 / $3,543.61 / $3,543.61
| Facility | | $3,543.61 | $3,543.61 | $3,543.61 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $2,171.67 / $2,171.67 / $2,171.67
| Facility | 62 | $2,171.67 | $2,171.67 | $2,171.67 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $347.47 / $347.47 / $347.47
| Facility | AS | $347.47 | $347.47 | $347.47 |