- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,187.76 / $2,187.76
| Facility | | $1,412.54 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,951.21
| Facility | | $2,398.83 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,890.45 / $3,890.45
| Facility | | $34.67 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | 62 | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $2,454.71
| Facility | | $1,174.90 | $1,174.90 | $2,454.71 |