- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,365.16 / $5,623.41
| Facility | | $1,445.44 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $3,981.07
| Facility | | $1,862.09 | $2,454.71 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,311.31 / $3,388.44
| Professional | | $3,162.28 | $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
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |