- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $9,772.37 / $15,488.17
| Facility | | $4,570.88 | $9,772.37 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,495.41 / $12,022.64
| Facility | | $2,137.96 | $5,495.41 | $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
- $912.01 / $1,122.02 / $2,884.03
| Professional | | $912.01 | $1,122.02 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $77.62 / $77.62 / $77.62
| Professional | 80 | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $38.90 / $38.90 / $38.90
| Professional | AS | $38.90 | $38.90 | $38.90 |
- 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 |