- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $4,365.16
| Facility | | $1,819.70 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,398.83 / $5,248.07
| Facility | | $1,659.59 | $2,398.83 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,570.88 / $4,897.79
| Professional | | $4,466.84 | $4,570.88 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,311.31 / $3,981.07
| Professional | | $2,238.72 | $3,311.31 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Professional | 80 | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Professional | AS | $776.25 | $776.25 | $776.25 |
- 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 |