- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.37 / $362.69 / $1,400.00
| Facility | | $182.37 | $362.69 | $1,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.79 / $280.88 / $306.02
| Facility | | $242.79 | $280.88 | $306.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.63 / $260.63 / $260.63
| Facility | | $260.63 | $260.63 | $260.63 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $159.84 / $159.84 / $159.84
| Facility | 62 | $159.84 | $159.84 | $159.84 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $25.58 / $25.58 / $25.58
| Facility | AS | $25.58 | $25.58 | $25.58 |