- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,370.32 / $7,943.28
| Facility | | $2,691.53 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,691.53 / $5,370.32
| Professional | | $1,513.56 | $2,691.53 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,951.21 / $4,786.30
| Facility | | $1,621.81 | $2,951.21 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Facility | 52 | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | AS | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,715.35 / $4,365.16
| Professional | | $2,951.21 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $7,413.10
| Facility | | $1,318.26 | $4,897.79 | $7,413.10 |