- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,165.95 / $10,232.93
| Facility | | $2,290.87 | $6,165.95 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $5,888.44
| Professional | | $1,380.38 | $2,089.30 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,801.89 / $15,488.17
| Facility | | $2,290.87 | $3,801.89 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | 52 | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $676.08 / $676.08 / $676.08
| Facility | AS | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,548.13 / $3,890.45
| Professional | | $3,019.95 | $3,548.13 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $16,218.10 / $34,673.69
| Facility | | $10,471.29 | $16,218.10 | $34,673.69 |