- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,279.97 / $9,046.94 / $19,813.83
| Facility | | $6,279.97 | $9,046.94 | $19,813.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.35 / $1,548.62 / $2,264.62
| Professional | | $1,291.35 | $1,548.62 | $2,264.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.82 / $1,956.48 / $2,761.53
| Professional | | $1,511.82 | $1,956.48 | $2,761.53 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $211.65 / $273.89 / $386.61
| Professional | AS | $211.65 | $273.89 | $386.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.48 / $2,196.63 / $3,104.79
| Professional | | $1,464.48 | $2,196.63 | $3,104.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,802.96 / $2,086.02 / $3,200.07
| Professional | | $1,802.96 | $2,086.02 | $3,200.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,126.48 / $15,823.91 / $27,025.20
| Facility | | $8,126.48 | $15,823.91 | $27,025.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,331.88 / $1,830.51 / $2,677.83
| Professional | | $1,331.88 | $1,830.51 | $2,677.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.20 / $1,964.27 / $2,860.65
| Professional | | $1,391.20 | $1,964.27 | $2,860.65 |