- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,370.32 / $9,549.93
| Facility | | $1,318.26 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,548.13 / $6,760.83
| Facility | | $1,348.96 | $3,548.13 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $3,235.94
| Professional | | $1,148.15 | $1,513.56 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $77.62 / $77.62 / $77.62
| Professional | 80 | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $38.90 / $38.90 / $38.90
| Professional | AS | $38.90 | $38.90 | $38.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $7,943.28
| Facility | | $602.56 | $3,235.94 | $7,943.28 |