- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,365.16 / $4,897.79
| Facility | | $1,318.26 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $3,467.37
| Facility | | $1,698.24 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,019.95 / $3,019.95
| Professional | | $2,818.38 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $2,630.27
| Professional | | $1,548.82 | $2,238.72 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | 80 | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Professional | AS | $512.86 | $512.86 | $512.86 |
- 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 |