- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,433.80 / $1,433.80 / $4,338.00
| Facility | | $1,433.80 | $1,433.80 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,879.31 / $2,423.12 / $3,869.97
| Facility | | $1,879.31 | $2,423.12 | $3,869.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,189.30 / $3,307.42 / $4,695.88
| Facility | | $2,189.30 | $3,307.42 | $4,695.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,865.39 / $2,566.21 / $3,014.55
| Professional | | $1,865.39 | $2,566.21 | $3,014.55 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $564.67 / $564.67 / $564.67
| Professional | 80 | $564.67 | $564.67 | $564.67 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $564.67 / $564.67 / $564.67
| Professional | AS | $564.67 | $564.67 | $564.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,571.00 / $6,571.00 / $6,571.00
| Facility | | $6,571.00 | $6,571.00 | $6,571.00 |