- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,166.91 / $1,166.91 / $1,166.91
| Facility | | $1,166.91 | $1,166.91 | $1,166.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,442.11 / $1,972.08 / $3,147.31
| Facility | | $1,442.11 | $1,972.08 | $3,147.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,150.00 / $2,666.77 / $3,581.11
| Facility | | $2,150.00 | $2,666.77 | $3,581.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.83 / $1,954.13 / $2,227.92
| Professional | | $1,470.83 | $1,954.13 | $2,227.92 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $437.67 / $437.67 / $437.67
| Professional | 80 | $437.67 | $437.67 | $437.67 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $437.67 / $437.67 / $437.67
| Professional | AS | $437.67 | $437.67 | $437.67 |
- 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 |