- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,276.46 / $2,276.46 / $4,338.00
| Facility | | $2,276.46 | $2,276.46 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,764.67 / $3,699.41 / $6,222.74
| Facility | | $2,764.67 | $3,699.41 | $6,222.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,551.25 / $5,286.71 / $7,407.25
| Facility | | $3,551.25 | $5,286.71 | $7,407.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,956.56 / $4,048.64 / $4,699.08
| Professional | | $2,956.56 | $4,048.64 | $4,699.08 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $899.40 / $899.40 / $899.40
| Professional | 80 | $899.40 | $899.40 | $899.40 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $899.40 / $899.40 / $899.40
| Professional | AS | $899.40 | $899.40 | $899.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |