- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $4,365.16
| Facility | | $1,698.24 | $1,698.24 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $4,265.80
| Facility | | $2,089.30 | $2,630.27 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,801.89
| Professional | | $3,630.78 | $3,630.78 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,884.03 / $3,235.94
| Professional | | $2,187.76 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | 80 | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $660.69 / $660.69 / $660.69
| Professional | AS | $660.69 | $660.69 | $660.69 |
- 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 |