- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $4,365.16 / $5,623.41
| Facility | | $1,288.25 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $3,019.95
| Facility | | $1,584.89 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $3,019.95
| Professional | | $2,187.76 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,187.76 / $2,691.53
| Professional | | $1,174.90 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Professional | 80 | $524.81 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $524.81 / $524.81 / $524.81
| Professional | AS | $524.81 | $524.81 | $524.81 |
- 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 |