- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $335.61 / $335.61 / $639.62
| Facility | | $335.61 | $335.61 | $639.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $686.78 / $1,078.17 / $1,936.58
| Facility | | $686.78 | $1,078.17 | $1,936.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,043.64 / $1,573.55 / $2,193.08
| Facility | | $1,043.64 | $1,573.55 | $2,193.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.74 / $1,172.00 / $1,377.25
| Professional | | $784.74 | $1,172.00 | $1,377.25 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $261.24 / $261.24 / $261.24
| Professional | 80 | $261.24 | $261.24 | $261.24 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $261.24 / $261.24 / $261.24
| Professional | AS | $261.24 | $261.24 | $261.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |