- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,262.90 / $7,902.10 / $14,853.20
| Facility | | $6,262.90 | $7,902.10 | $14,853.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.54 / $961.76 / $1,671.12
| Facility | | $600.54 | $961.76 | $1,671.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $895.41 / $1,348.00 / $1,878.16
| Facility | | $895.41 | $1,348.00 | $1,878.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.41 / $1,006.65 / $1,183.18
| Professional | | $744.41 | $1,006.65 | $1,183.18 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $224.17 / $224.17 / $224.17
| Professional | 80 | $224.17 | $224.17 | $224.17 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $224.17 / $224.17 / $224.17
| Professional | AS | $224.17 | $224.17 | $224.17 |
- 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 |