- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.69 / $2,460.69 / $2,460.69
| Facility | | $2,460.69 | $2,460.69 | $2,460.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,365.17 / $3,850.72 / $6,417.33
| Facility | | $2,365.17 | $3,850.72 | $6,417.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,937.92 / $5,467.70 / $7,454.17
| Facility | | $3,937.92 | $5,467.70 | $7,454.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,046.73 / $4,077.34 / $4,648.62
| Professional | | $3,046.73 | $4,077.34 | $4,648.62 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $909.95 / $909.95 / $909.95
| Professional | 80 | $909.95 | $909.95 | $909.95 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $909.95 / $909.95 / $909.95
| Professional | AS | $909.95 | $909.95 | $909.95 |
- 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 |