- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,548.13 / $4,365.16
| Facility | | $1,047.13 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,584.89 / $3,162.28
| Facility | | $933.25 | $1,584.89 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,630.27 / $2,754.23
| Professional | | $2,454.71 | $2,630.27 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $2,187.76
| Professional | | $1,288.25 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | 80 | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | AS | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |