- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,365.16 / $4,897.79
| Facility | | $1,819.70 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,090.30 / $4,897.79
| Facility | | $2,398.83 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,265.80 / $4,265.80
| Professional | | $3,890.45 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $3,630.78
| Professional | | $2,238.72 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Professional | 80 | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Professional | AS | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |