- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,451.60 / $8,104.68 / $15,777.27
| Facility | | $3,451.60 | $8,104.68 | $15,777.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.51 / $1,317.69 / $2,319.19
| Professional | | $931.51 | $1,317.69 | $2,319.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,021.10 / $1,225.32 / $1,531.65
| Facility | | $1,021.10 | $1,225.32 | $1,531.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.10 / $1,531.65 / $2,367.48
| Professional | | $1,021.10 | $1,531.65 | $2,367.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,211.14 / $1,211.14 / $1,211.14
| Facility | | $1,211.14 | $1,211.14 | $1,211.14 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $120.27 / $120.27 / $120.27
| Facility | AS | $120.27 | $120.27 | $120.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.14 / $1,569.54 / $2,999.46
| Professional | | $1,033.14 | $1,569.54 | $2,999.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,790.42 / $23,519.54 / $32,166.75
| Facility | | $5,790.42 | $23,519.54 | $32,166.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,456.03 / $1,671.60 / $2,443.26
| Professional | | $1,456.03 | $1,671.60 | $2,443.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.56 / $1,245.65 / $1,749.55
| Professional | | $846.56 | $1,245.65 | $1,749.55 |