- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,623.41 / $26,915.35
| Facility | | $1,862.09 | $5,623.41 | $26,915.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,162.28 / $5,011.87
| Facility | | $2,454.71 | $3,162.28 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,365.16 / $4,365.16
| Professional | | $3,981.07 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $3,715.35
| Professional | | $2,290.87 | $3,235.94 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Professional | 80 | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Professional | AS | $724.44 | $724.44 | $724.44 |
- 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 |