- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.76 / $1,650.76 / $1,650.76
| Facility | | $1,650.76 | $1,650.76 | $1,650.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,782.08 / $2,585.44 / $4,292.21
| Facility | | $1,782.08 | $2,585.44 | $4,292.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,711.00 / $3,658.46 / $5,011.85
| Facility | | $2,711.00 | $3,658.46 | $5,011.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,040.17 / $2,748.49 / $3,133.58
| Professional | | $2,040.17 | $2,748.49 | $3,133.58 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $609.72 / $609.72 / $609.72
| Professional | 80 | $609.72 | $609.72 | $609.72 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $609.72 / $609.72 / $609.72
| Professional | AS | $609.72 | $609.72 | $609.72 |
- 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 |