- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,246.05 / $1,246.05 / $4,338.00
| Facility | | $1,246.05 | $1,246.05 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,345.27 / $2,105.82 / $3,831.53
| Facility | | $1,345.27 | $2,105.82 | $3,831.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,072.03 / $3,112.12 / $4,301.70
| Facility | | $2,072.03 | $3,112.12 | $4,301.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.88 / $2,326.60 / $2,698.22
| Professional | | $1,710.88 | $2,326.60 | $2,698.22 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $516.42 / $516.42 / $516.42
| Professional | 80 | $516.42 | $516.42 | $516.42 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $516.42 / $516.42 / $516.42
| Professional | AS | $516.42 | $516.42 | $516.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $4,500.00
| Facility | | $4,500.00 | $4,500.00 | $4,500.00 |