- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,981.07 / $6,760.83
| Facility | | $3,388.44 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,311.31 / $13,803.84
| Professional | | $2,089.30 | $3,311.31 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,168.69 / $6,606.93
| Facility | | $1,445.44 | $4,168.69 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Facility | 62 | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,623.41 / $7,943.28
| Professional | | $5,011.87 | $5,623.41 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,897.79 / $7,585.78
| Facility | | $1,445.44 | $4,897.79 | $7,585.78 |