- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $4,365.16
| Facility | | $912.01 | $912.01 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $2,290.87
| Facility | | $812.83 | $1,258.93 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,344.23
| Professional | | $1,949.84 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,513.56 / $1,737.80
| Professional | | $1,174.90 | $1,513.56 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Professional | 80 | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $398.11 / $398.11 / $398.11
| Professional | AS | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |