- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $6,456.54 / $7,943.28
| Facility | | $1,995.26 | $6,456.54 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,090.30 / $30,199.52
| Professional | | $1,071.52 | $3,090.30 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $177.83 / $446.68 / $758.58
| Professional | AS | $177.83 | $446.68 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $6,918.31 / $15,135.61
| Professional | | $1,412.54 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,570.40 / $3,548.13
| Professional | | $1,288.25 | $2,570.40 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,754.23 / $2,951.21
| Professional | | $1,202.26 | $2,754.23 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $25,703.96 / $63,095.73
| Facility | | $9,120.11 | $25,703.96 | $63,095.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,995.26 / $4,677.35
| Professional | | $1,288.25 | $1,995.26 | $4,677.35 |