- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $4,365.16
| Facility | | $2,454.71 | $2,454.71 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,235.94 / $6,309.57
| Facility | | $2,344.23 | $3,235.94 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,495.41
| Professional | | $5,248.07 | $5,248.07 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,073.80 / $4,677.35
| Professional | | $2,951.21 | $4,073.80 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | 80 | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | AS | $933.25 | $933.25 | $933.25 |
- 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 |