- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $3,548.13 / $4,365.16
| Facility | | $724.44 | $3,548.13 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $2,238.72
| Facility | | $977.24 | $1,230.27 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $1,905.46
| Professional | | $1,659.59 | $1,778.28 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,380.38 / $1,584.89
| Professional | | $1,071.52 | $1,380.38 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | 80 | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | AS | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Facility | | $7,079.46 | $7,079.46 | $7,079.46 |