- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $2,238.72 / $4,365.16
| Facility | | $371.54 | $2,238.72 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $630.96 / $977.24
| Facility | | $489.78 | $630.96 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $851.14 / $851.14
| Professional | | $758.58 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $630.96 / $741.31
| Professional | | $446.68 | $630.96 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | 80 | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | AS | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |