- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,365.16 / $4,897.79
| Facility | | $1,202.26 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,235.94
| Facility | | $1,548.82 | $2,041.74 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,818.38 / $2,818.38
| Professional | | $2,570.40 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,041.74 / $2,398.83
| Professional | | $1,348.96 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Professional | 80 | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Professional | AS | $467.74 | $467.74 | $467.74 |
- 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 |