- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,365.16 / $5,623.41
| Facility | | $1,122.02 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,862.09 / $2,951.21
| Facility | | $1,445.44 | $1,862.09 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,570.40 / $2,570.40
| Professional | | $2,344.23 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $2,238.72
| Professional | | $1,318.26 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | 80 | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | AS | $436.52 | $436.52 | $436.52 |
- 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 |