- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,127.17 / $8,833.50 / $11,492.20
| Facility | | $1,127.17 | $8,833.50 | $11,492.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,484.65 / $1,904.92 / $3,038.84
| Facility | | $1,484.65 | $1,904.92 | $3,038.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,090.32 / $3,055.06 / $21,343.15
| Facility | | $2,090.32 | $3,055.06 | $21,343.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.89 / $1,942.51 / $2,255.73
| Professional | | $1,424.89 | $1,942.51 | $2,255.73 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $430.08 / $430.08 / $430.08
| Professional | 80 | $430.08 | $430.08 | $430.08 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $430.08 / $430.08 / $430.08
| Professional | AS | $430.08 | $430.08 | $430.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $6,571.00 / $6,571.00
| Facility | | $6,571.00 | $6,571.00 | $6,571.00 |