- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.13 / $705.42 / $2,290.00
| Facility | | $347.13 | $705.42 | $2,290.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $855.55 / $1,231.70 / $1,985.45
| Facility | | $855.55 | $1,231.70 | $1,985.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,124.90 / $1,683.26 / $2,346.37
| Facility | | $1,124.90 | $1,683.26 | $2,346.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.34 / $1,300.48 / $1,482.69
| Professional | | $938.34 | $1,300.48 | $1,482.69 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $287.23 / $287.23 / $287.23
| Professional | 80 | $287.23 | $287.23 | $287.23 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $287.23 / $287.23 / $287.23
| Professional | AS | $287.23 | $287.23 | $287.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.00 / $821.00 / $821.00
| Facility | | $821.00 | $821.00 | $821.00 |