- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,365.16 / $4,897.79
| Facility | | $1,445.44 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $3,890.45
| Facility | | $1,905.46 | $2,454.71 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,311.31 / $3,388.44
| Professional | | $3,090.30 | $3,311.31 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,570.40 / $3,019.95
| Professional | | $1,698.24 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | 80 | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | AS | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |