- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,602.73 / $5,045.00 / $6,915.00
| Facility | | $1,602.73 | $5,045.00 | $6,915.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,325.76 / $8,967.21 / $21,657.35
| Facility | | $2,325.76 | $8,967.21 | $21,657.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.00 / $550.00 / $550.00
| Facility | | $550.00 | $550.00 | $550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,577.58 / $2,208.61 / $4,422.56
| Professional | | $1,577.58 | $2,208.61 | $4,422.56 |
- Facility/Professional
- Professional
- Modifier
- 62
- Low / Median / High Price
- $1,710.86 / $1,710.86 / $1,710.86
| Professional | 62 | $1,710.86 | $1,710.86 | $1,710.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $607.00 / $3,629.00 / $10,000.00
| Facility | | $607.00 | $3,629.00 | $10,000.00 |