- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.21 / $2,290.21 / $2,290.21
| Facility | | $2,290.21 | $2,290.21 | $2,290.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,205.52 / $3,870.45 / $5,960.82
| Facility | | $2,205.52 | $3,870.45 | $5,960.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,096.00 / $5,338.55 / $6,946.32
| Facility | | $4,096.00 | $5,338.55 | $6,946.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.77 / $3,800.45 / $4,332.93
| Professional | | $2,831.77 | $3,800.45 | $4,332.93 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $845.35 / $845.35 / $845.35
| Professional | 80 | $845.35 | $845.35 | $845.35 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $845.35 / $845.35 / $845.35
| Professional | AS | $845.35 | $845.35 | $845.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |