- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,370.32 / $9,549.93
| Facility | | $1,737.80 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,888.44 / $12,022.64
| Facility | | $2,238.72 | $5,888.44 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $758.58 / $1,778.28
| Professional | | $630.96 | $758.58 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $54.95 / $54.95 / $54.95
| Professional | 80 | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $27.54 / $27.54 / $27.54
| Professional | AS | $27.54 | $27.54 | $27.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,918.31 / $12,022.64
| Facility | | $1,737.80 | $6,918.31 | $12,022.64 |