- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,248.07 / $7,943.28
| Facility | | $1,905.46 | $5,248.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,737.80 / $5,248.07
| Professional | | $1,148.15 | $1,737.80 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,344.23 / $8,511.38
| Facility | | $794.33 | $2,344.23 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- 54
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | 54 | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | AS | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,019.95 / $3,311.31
| Professional | | $2,630.27 | $3,019.95 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $11,481.54 / $19,498.45
| Facility | | $7,413.10 | $11,481.54 | $19,498.45 |