- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $772.20 / $772.20 / $772.20
| Facility | | $772.20 | $772.20 | $772.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $807.12 / $1,305.02 / $2,340.69
| Facility | | $807.12 | $1,305.02 | $2,340.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,259.63 / $1,898.70 / $2,647.75
| Facility | | $1,259.63 | $1,898.70 | $2,647.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.22 / $1,418.01 / $1,661.89
| Professional | | $920.22 | $1,418.01 | $1,661.89 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $315.29 / $315.29 / $315.29
| Professional | 80 | $315.29 | $315.29 | $315.29 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $315.29 / $315.29 / $315.29
| Professional | AS | $315.29 | $315.29 | $315.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |