- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $4,365.16
| Facility | | $912.01 | $912.01 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $1,380.38 / $2,691.53
| Facility | | $831.76 | $1,380.38 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $2,454.71
| Professional | | $2,187.76 | $2,290.87 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $1,949.84
| Professional | | $1,148.15 | $1,621.81 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $389.05 / $389.05 / $389.05
| Professional | 80 | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $389.05 / $389.05 / $389.05
| Professional | AS | $389.05 | $389.05 | $389.05 |
- 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 |