- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,218.00 / $3,576.15 / $7,119.04
| Facility | | $2,218.00 | $3,576.15 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.18 / $1,241.79 / $2,634.54
| Professional | | $755.18 | $1,241.79 | $2,634.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,226.47 / $1,787.47 / $2,324.71
| Facility | | $1,226.47 | $1,787.47 | $2,324.71 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $2,323.71 / $2,323.71 / $2,323.71
| Facility | 62 | $2,323.71 | $2,323.71 | $2,323.71 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $371.79 / $371.79 / $371.79
| Facility | AS | $371.79 | $371.79 | $371.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,408.13 / $1,801.83 / $2,334.81
| Facility | | $1,408.13 | $1,801.83 | $2,334.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,204.00 / $1,640.00 / $2,126.00
| Facility | | $1,204.00 | $1,640.00 | $2,126.00 |