- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,964.00 / $6,066.00 / $7,119.04
| Facility | | $4,964.00 | $6,066.00 | $7,119.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,626.79 / $2,540.82 / $4,849.25
| Professional | | $1,626.79 | $2,540.82 | $4,849.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,079.94 / $3,268.66 / $4,962.76
| Facility | | $2,079.94 | $3,268.66 | $4,962.76 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $6,402.84 / $6,402.84 / $6,402.84
| Facility | 52 | $6,402.84 | $6,402.84 | $6,402.84 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $800.36 / $800.36 / $800.36
| Facility | AS | $800.36 | $800.36 | $800.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,646.09 / $3,847.86 / $5,204.66
| Facility | | $2,646.09 | $3,847.86 | $5,204.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,321.00 / $5,847.00 / $7,856.00
| Facility | | $1,321.00 | $5,847.00 | $7,856.00 |