- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $911.85 / $911.85 / $5,216.39
| Facility | | $911.85 | $911.85 | $5,216.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,221.03 / $1,541.03 / $2,660.92
| Facility | | $1,221.03 | $1,541.03 | $2,660.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,536.73 / $2,502.37 / $3,134.75
| Facility | | $1,536.73 | $2,502.37 | $3,134.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,249.35 / $1,688.19 / $1,985.98
| Professional | | $1,249.35 | $1,688.19 | $1,985.98 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $374.48 / $374.48 / $374.48
| Professional | 80 | $374.48 | $374.48 | $374.48 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $374.48 / $374.48 / $374.48
| Professional | AS | $374.48 | $374.48 | $374.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |