- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $4,365.16
| Facility | | $2,290.87 | $2,290.87 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $5,754.40
| Facility | | $2,818.38 | $3,548.13 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,128.61
| Professional | | $4,897.79 | $4,897.79 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,801.89 / $4,365.16
| Professional | | $2,818.38 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $870.96 / $870.96 / $870.96
| Professional | 80 | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $870.96 / $870.96 / $870.96
| Professional | AS | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |