- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $5,248.07 / $7,943.28
| Facility | | $2,344.23 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,089.30 / $4,073.80
| Professional | | $1,348.96 | $2,089.30 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,388.44 / $11,481.54
| Facility | | $1,905.46 | $3,388.44 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | 62 | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Facility | AS | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,388.44 / $4,073.80
| Professional | | $2,951.21 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $11,748.98 / $19,498.45
| Facility | | $8,511.38 | $11,748.98 | $19,498.45 |