- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $711.75 / $711.75 / $4,338.00
| Facility | | $711.75 | $711.75 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $931.63 / $1,173.64 / $1,872.69
| Facility | | $931.63 | $1,173.64 | $1,872.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,068.76 / $1,636.02 / $2,284.84
| Facility | | $1,068.76 | $1,636.02 | $2,284.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.53 / $1,242.77 / $1,461.99
| Professional | | $903.53 | $1,242.77 | $1,461.99 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $270.76 / $270.76 / $270.76
| Professional | 80 | $270.76 | $270.76 | $270.76 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $270.76 / $270.76 / $270.76
| Professional | AS | $270.76 | $270.76 | $270.76 |
- 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 |