- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.27 / $1,216.27 / $4,338.00
| Facility | | $1,216.27 | $1,216.27 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.39 / $2,074.16 / $3,359.35
| Facility | | $1,631.39 | $2,074.16 | $3,359.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,302.50 / $3,430.40 / $8,250.46
| Facility | | $2,302.50 | $3,430.40 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.33 / $2,194.90 / $2,552.67
| Professional | | $1,600.33 | $2,194.90 | $2,552.67 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $484.25 / $484.25 / $484.25
| Professional | 80 | $484.25 | $484.25 | $484.25 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $484.25 / $484.25 / $484.25
| Professional | AS | $484.25 | $484.25 | $484.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |