- 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
- $3,162.28 / $5,495.41 / $13,803.84
| Professional | | $3,162.28 | $5,495.41 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,918.31 / $9,120.11
| Facility | | $3,019.95 | $6,918.31 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | 62 | $9,549.93 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $7,244.36 / $10,471.29
| Professional | | $6,918.31 | $7,244.36 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |