- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,060.90 / $1,060.90 / $4,338.00
| Facility | | $1,060.90 | $1,060.90 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,365.09 / $1,792.92 / $3,418.51
| Facility | | $1,365.09 | $1,792.92 | $3,418.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.00 / $3,337.08 / $8,958.90
| Facility | | $2,200.00 | $3,337.08 | $8,958.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,559.59 / $2,066.29 / $2,174.88
| Professional | | $1,559.59 | $2,066.29 | $2,174.88 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $475.63 / $475.63 / $475.63
| Professional | 80 | $475.63 | $475.63 | $475.63 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $475.63 / $475.63 / $475.63
| Professional | AS | $475.63 | $475.63 | $475.63 |
- 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 |