- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,365.16
| Facility | | $3,388.44 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,466.84 / $8,511.38
| Facility | | $3,090.30 | $4,466.84 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,244.36 / $7,244.36 / $7,585.78
| Professional | | $7,244.36 | $7,244.36 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,623.41 / $6,456.54
| Professional | | $4,073.80 | $5,623.41 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | 80 | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,288.25
| Professional | AS | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |