- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39,810.72 / $39,810.72 / $39,810.72
| Facility | | $39,810.72 | $39,810.72 | $39,810.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $630.96
| Facility | | $575.44 | $602.56 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | 62 | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Facility | AS | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $354.81 / $524.81
| Professional | | $275.42 | $354.81 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $1,479.11 / $3,388.44
| Facility | | $331.13 | $1,479.11 | $3,388.44 |