- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $6,025.60 / $7,943.28
| Facility | | $1,995.26 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,862.09 / $3,311.31
| Professional | | $1,148.15 | $1,862.09 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,884.03 / $14,125.38
| Facility | | $1,819.70 | $2,884.03 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | 62 | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Facility | AS | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $3,548.13
| Professional | | $2,454.71 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,218.10 / $46,773.51
| Facility | | $10,471.29 | $16,218.10 | $46,773.51 |