- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,677.35 / $9,332.54
| Facility | | $3,235.94 | $4,677.35 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $812.83 / $1,778.28
| Facility | | $676.08 | $812.83 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,348.96 / $1,380.38
| Professional | | $1,258.93 | $1,348.96 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $1,202.26
| Professional | | $741.31 | $1,047.13 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | 80 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | AS | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |