- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,370.32 / $7,943.28
| Facility | | $2,290.87 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,235.94 / $5,888.44
| Professional | | $1,737.80 | $3,235.94 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,570.88 / $11,481.54
| Facility | | $2,454.71 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $6,918.31
| Facility | 52 | $6,918.31 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $851.14 / $851.14 / $851.14
| Facility | AS | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,265.80 / $10,471.29
| Professional | | $3,388.44 | $4,265.80 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,413.10 / $12,302.69
| Facility | | $4,570.88 | $7,413.10 | $12,302.69 |