- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $4,365.16 / $6,918.31
| Facility | | $912.01 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $2,691.53
| Facility | | $1,230.27 | $1,548.82 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,238.72 / $2,290.87
| Professional | | $2,089.30 | $2,238.72 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,698.24 / $1,995.26
| Professional | | $1,174.90 | $1,698.24 | $1,995.26 |
- 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
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |