- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,370.32 / $7,943.28
| Facility | | $4,265.80 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,897.79 / $9,772.37
| Professional | | $2,951.21 | $4,897.79 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,128.61 / $7,762.47
| Facility | | $2,754.23 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Facility | 62 | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,244.36 / $8,128.31
| Professional | | $4,570.88 | $7,244.36 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |