- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $956.80 / $956.80 / $3,073.00
| Facility | | $956.80 | $956.80 | $3,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.94 / $1,166.02 / $2,391.14
| Facility | | $784.94 | $1,166.02 | $2,391.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,686.17 / $1,946.86 / $2,341.67
| Facility | | $1,686.17 | $1,946.86 | $2,341.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.68 / $1,471.10 / $1,730.46
| Professional | | $976.68 | $1,471.10 | $1,730.46 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $332.14 / $332.14 / $332.14
| Professional | 80 | $332.14 | $332.14 | $332.14 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $332.14 / $332.14 / $332.14
| Professional | AS | $332.14 | $332.14 | $332.14 |
- 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 |