- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,461.98 / $2,461.98 / $2,461.98
| Facility | | $2,461.98 | $2,461.98 | $2,461.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,366.44 / $4,160.75 / $6,422.24
| Facility | | $2,366.44 | $4,160.75 | $6,422.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,428.00 / $5,741.72 / $7,455.22
| Facility | | $4,428.00 | $5,741.72 | $7,455.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,050.16 / $4,079.04 / $4,650.56
| Professional | | $3,050.16 | $4,079.04 | $4,650.56 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $911.11 / $911.11 / $911.11
| Professional | 80 | $911.11 | $911.11 | $911.11 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $911.11 / $911.11 / $911.11
| Professional | AS | $911.11 | $911.11 | $911.11 |
- 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 |