- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $5,128.61 / $8,317.64
| Facility | | $1,288.25 | $5,128.61 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,801.89 / $5,888.44
| Facility | | $1,318.26 | $3,801.89 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $1,659.59 / $2,630.27
| Facility | | $512.86 | $1,659.59 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $812.83 / $1,621.81
| Professional | | $630.96 | $812.83 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $47.86 / $47.86 / $60.26
| Professional | 80 | $47.86 | $47.86 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $23.44 / $23.44 / $30.20
| Professional | AS | $23.44 | $23.44 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $4,677.35 / $8,511.38
| Facility | | $660.69 | $4,677.35 | $8,511.38 |