- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $5,370.32 / $9,549.93
| Facility | | $1,778.28 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $6,606.93
| Facility | | $851.14 | $3,162.28 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $616.60 / $831.76
| Facility | | $398.11 | $616.60 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,348.96 / $2,511.89
| Professional | | $1,023.29 | $1,348.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $79.43 / $79.43 / $102.33
| Professional | 80 | $79.43 | $79.43 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $39.81 / $39.81 / $51.29
| Professional | AS | $39.81 | $39.81 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,511.89 / $7,079.46
| Facility | | $398.11 | $2,511.89 | $7,079.46 |