- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $6,760.83 / $14,454.40
| Facility | | $1,905.46 | $6,760.83 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,248.07 / $12,022.64
| Facility | | $2,137.96 | $5,248.07 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $16,218.10 / $24,547.09
| Facility | | $6,165.95 | $16,218.10 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $2,754.23
| Professional | | $758.58 | $954.99 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $66.07 / $66.07 / $66.07
| Professional | 80 | $66.07 | $66.07 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $33.11 / $33.11 / $33.11
| Professional | AS | $33.11 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $7,762.47 / $17,378.01
| Facility | | $1,995.26 | $7,762.47 | $17,378.01 |