- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,550.72 / $6,577.71 / $34,437.50
| Facility | | $1,550.72 | $6,577.71 | $34,437.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,688.04 / $2,809.96 / $4,780.39
| Facility | | $1,688.04 | $2,809.96 | $4,780.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,582.88 / $3,880.34 / $5,401.87
| Facility | | $2,582.88 | $3,880.34 | $5,401.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,917.77 / $2,909.12 / $3,386.52
| Professional | | $1,917.77 | $2,909.12 | $3,386.52 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $646.53 / $646.53 / $646.53
| Professional | 80 | $646.53 | $646.53 | $646.53 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $646.53 / $646.53 / $646.53
| Professional | AS | $646.53 | $646.53 | $646.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |