- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $979.31 / $979.31 / $4,338.00
| Facility | | $979.31 | $979.31 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.73 / $1,655.03 / $2,854.96
| Facility | | $1,060.73 | $1,655.03 | $2,854.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,633.64 / $2,455.81 / $3,394.41
| Facility | | $1,633.64 | $2,455.81 | $3,394.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.80 / $1,835.75 / $2,127.65
| Professional | | $1,246.80 | $1,835.75 | $2,127.65 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $408.71 / $408.71 / $408.71
| Professional | 80 | $408.71 | $408.71 | $408.71 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $408.71 / $408.71 / $408.71
| Professional | AS | $408.71 | $408.71 | $408.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |