- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $12,302.69 / $18,197.01
| Facility | | $4,365.16 | $12,302.69 | $18,197.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,290.87 / $6,309.57
| Facility | | $1,230.27 | $2,290.87 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,467.37 / $3,630.78
| Professional | | $3,388.44 | $3,467.37 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $2,951.21
| Professional | | $1,905.46 | $2,570.40 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Professional | 80 | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Professional | AS | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |