- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $974.18 / $974.18 / $1,400.00
| Facility | | $974.18 | $974.18 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,099.29 / $1,265.58 / $1,378.86
| Facility | | $1,099.29 | $1,265.58 | $1,378.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,182.14 / $1,182.14 / $1,182.14
| Facility | | $1,182.14 | $1,182.14 | $1,182.14 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $735.39 / $735.39 / $735.39
| Facility | 62 | $735.39 | $735.39 | $735.39 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $117.66 / $117.66 / $117.66
| Facility | AS | $117.66 | $117.66 | $117.66 |