- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,128.61 / $9,549.93
| Facility | | $1,584.89 | $5,128.61 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,890.45 / $6,918.31
| Facility | | $1,548.82 | $3,890.45 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,047.13 / $2,238.72
| Professional | | $851.14 | $1,047.13 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $74.13 / $74.13 / $74.13
| Professional | 80 | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $37.15 / $37.15 / $37.15
| Professional | AS | $37.15 | $37.15 | $37.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,754.40 / $8,511.38
| Facility | | $1,513.56 | $5,754.40 | $8,511.38 |