- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,365.16
| Facility | | $2,041.74 | $2,041.74 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,162.28 / $5,128.61
| Facility | | $2,511.89 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $4,365.16 / $4,570.88
| Professional | | $4,365.16 | $4,365.16 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,388.44 / $3,890.45
| Professional | | $2,454.71 | $3,388.44 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Professional | 80 | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Professional | AS | $776.25 | $776.25 | $776.25 |
- 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 |