- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $4,365.16
| Facility | | $2,238.72 | $2,238.72 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,388.44 / $6,309.57
| Facility | | $2,630.27 | $3,388.44 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,370.32 / $5,370.32
| Professional | | $5,011.87 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,168.69 / $4,786.30
| Professional | | $2,884.03 | $4,168.69 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | 80 | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | AS | $933.25 | $933.25 | $933.25 |
- 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 |