- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $4,365.16
| Facility | | $1,122.02 | $1,122.02 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,905.46 / $2,884.03
| Facility | | $1,479.11 | $1,905.46 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,511.89
| Professional | | $2,398.83 | $2,398.83 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $2,137.96
| Professional | | $1,318.26 | $1,949.84 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | 80 | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Professional | AS | $436.52 | $436.52 | $436.52 |
- 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 |