- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.46 / $1,181.46 / $4,338.00
| Facility | | $1,181.46 | $1,181.46 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,547.99 / $1,996.67 / $3,143.29
| Facility | | $1,547.99 | $1,996.67 | $3,143.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,806.83 / $2,720.09 / $3,708.32
| Facility | | $1,806.83 | $2,720.09 | $3,708.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.84 / $2,010.97 / $2,361.19
| Professional | | $1,481.84 | $2,010.97 | $2,361.19 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $445.78 / $445.78 / $445.78
| Professional | 80 | $445.78 | $445.78 | $445.78 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $445.78 / $445.78 / $445.78
| Professional | AS | $445.78 | $445.78 | $445.78 |
- 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 |