- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,213.63 / $1,213.63 / $1,400.00
| Facility | | $1,213.63 | $1,213.63 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.72 / $1,512.50 / $1,647.89
| Facility | | $1,357.72 | $1,512.50 | $1,647.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.49 / $1,453.49 / $1,453.49
| Facility | | $1,453.49 | $1,453.49 | $1,453.49 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $885.91 / $885.91 / $885.91
| Facility | 62 | $885.91 | $885.91 | $885.91 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $141.75 / $141.75 / $141.75
| Facility | AS | $141.75 | $141.75 | $141.75 |