- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,277.00 / $5,549.00 / $11,100.08
| Facility | | $4,277.00 | $5,549.00 | $11,100.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.75 / $1,701.08 / $2,784.49
| Professional | | $1,034.75 | $1,701.08 | $2,784.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.09 / $2,569.02 / $6,608.00
| Facility | | $1,875.09 | $2,569.02 | $6,608.00 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $3,220.63 / $3,220.63 / $3,220.63
| Facility | 62 | $3,220.63 | $3,220.63 | $3,220.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,615.40 / $2,410.23 / $3,152.42
| Facility | | $1,615.40 | $2,410.23 | $3,152.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,126.00 / $5,847.00 / $7,305.00
| Facility | | $2,126.00 | $5,847.00 | $7,305.00 |