- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,778.28 / $6,760.83
| Facility | | $316.23 | $1,778.28 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $524.81 / $954.99
| Facility | | $288.40 | $524.81 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $776.25 / $831.76
| Professional | | $758.58 | $776.25 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $562.34 / $676.08
| Professional | | $398.11 | $562.34 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Professional | 80 | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Professional | AS | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |