- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $4,365.16
| Facility | | $1,479.11 | $1,479.11 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,089.30 / $3,801.89
| Facility | | $1,862.09 | $2,089.30 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,311.31
| Professional | | $3,162.28 | $3,162.28 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $2,818.38
| Professional | | $1,737.80 | $2,454.71 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | 80 | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | AS | $562.34 | $562.34 | $562.34 |
- 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 |