- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,623.41 / $10,964.78
| Facility | | $1,698.24 | $5,623.41 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,801.89 / $7,244.36
| Facility | | $1,230.27 | $3,801.89 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,737.80 / $3,090.30
| Professional | | $1,348.96 | $1,737.80 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $120.23 / $120.23 / $120.23
| Professional | 80 | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Professional | AS | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $7,943.28
| Facility | | $602.56 | $3,235.94 | $7,943.28 |