- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,258.93 / $4,365.16
| Facility | | $1,258.93 | $1,258.93 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $1,737.80 / $3,090.30
| Facility | | $870.96 | $1,737.80 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $2,691.53
| Professional | | $2,630.27 | $2,630.27 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $2,041.74 / $2,344.23
| Professional | | $954.99 | $2,041.74 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Professional | 80 | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $457.09 / $457.09 / $457.09
| Professional | AS | $457.09 | $457.09 | $457.09 |
- 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 |