- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,570.88 / $7,413.10
| Facility | | $1,380.38 | $4,570.88 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $2,818.38 / $6,025.60
| Facility | | $724.44 | $2,818.38 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $616.60 / $831.76
| Facility | | $199.53 | $616.60 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,071.52 / $1,949.84
| Professional | | $831.76 | $1,071.52 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $63.10 / $63.10 / $79.43
| Professional | 80 | $63.10 | $63.10 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $31.62 / $31.62 / $39.81
| Professional | AS | $31.62 | $31.62 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $2,454.71 / $5,248.07
| Facility | | $524.81 | $2,454.71 | $5,248.07 |