- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,365.16 / $6,918.31
| Facility | | $1,122.02 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,737.80 / $3,388.44
| Facility | | $1,000.00 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,691.53 / $2,951.21
| Professional | | $2,630.27 | $2,691.53 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,949.84 / $2,290.87
| Professional | | $1,479.11 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | 80 | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | AS | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |