- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $4,365.16
| Facility | | $812.83 | $812.83 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,380.38 / $2,041.74
| Facility | | $1,071.52 | $1,380.38 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,819.70
| Professional | | $1,737.80 | $1,737.80 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $1,548.82
| Professional | | $1,047.13 | $1,380.38 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Professional | 80 | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Professional | AS | $316.23 | $316.23 | $316.23 |
- 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 |