- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $7,943.28
| Facility | | $3,162.28 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,801.89 / $9,332.54
| Professional | | $2,137.96 | $3,801.89 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,897.79 / $7,244.36
| Facility | | $2,344.23 | $4,897.79 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- 62
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $6,165.95
| Facility | 62 | $6,165.95 | $6,165.95 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Facility | AS | $977.24 | $977.24 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $7,079.46
| Professional | | $4,677.35 | $5,128.61 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $7,413.10
| Facility | | $2,137.96 | $5,248.07 | $7,413.10 |