- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,225.36 / $1,225.36 / $4,338.00
| Facility | | $1,225.36 | $1,225.36 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,587.00 / $2,069.67 / $3,260.96
| Facility | | $1,587.00 | $2,069.67 | $3,260.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.99 / $2,822.09 / $3,955.47
| Facility | | $1,855.99 | $2,822.09 | $3,955.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.22 / $2,163.31 / $2,544.90
| Professional | | $1,575.22 | $2,163.31 | $2,544.90 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $473.32 / $473.32 / $473.32
| Professional | 80 | $473.32 | $473.32 | $473.32 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $473.32 / $473.32 / $473.32
| Professional | AS | $473.32 | $473.32 | $473.32 |
- 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 |