- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $4,365.16
| Facility | | $1,122.02 | $1,122.02 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,698.24 / $3,235.94
| Facility | | $1,023.29 | $1,698.24 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $2,951.21
| Professional | | $2,691.53 | $2,818.38 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,995.26 / $2,398.83
| Professional | | $1,412.54 | $1,995.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Professional | 80 | $478.63 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $478.63 / $478.63 / $478.63
| Professional | AS | $478.63 | $478.63 | $478.63 |
- 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 |