- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,468.87 / $1,468.87 / $4,338.00
| Facility | | $1,468.87 | $1,468.87 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,929.96 / $2,445.85 / $4,034.91
| Facility | | $1,929.96 | $2,445.85 | $4,034.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.76 / $3,436.63 / $4,897.16
| Facility | | $2,290.76 | $3,436.63 | $4,897.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,950.80 / $2,663.12 / $3,088.30
| Professional | | $1,950.80 | $2,663.12 | $3,088.30 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $589.39 / $589.39 / $589.39
| Professional | 80 | $589.39 | $589.39 | $589.39 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $589.39 / $589.39 / $589.39
| Professional | AS | $589.39 | $589.39 | $589.39 |
- 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 |