- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,786.30 / $8,912.51
| Facility | | $1,445.44 | $4,786.30 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,630.78 / $6,918.31
| Facility | | $1,548.82 | $3,630.78 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $7,244.36 / $9,772.37
| Facility | | $4,168.69 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $851.14 / $2,187.76
| Professional | | $676.08 | $851.14 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | 80 | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $29.51 / $29.51 / $29.51
| Professional | AS | $29.51 | $29.51 | $29.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $7,244.36 / $14,125.38
| Facility | | $1,737.80 | $7,244.36 | $14,125.38 |