- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,247.55 / $1,247.55 / $1,247.55
| Facility | | $1,247.55 | $1,247.55 | $1,247.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,128.73 / $1,954.30 / $3,122.42
| Facility | | $1,128.73 | $1,954.30 | $3,122.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,114.00 / $2,681.15 / $3,728.13
| Facility | | $1,114.00 | $2,681.15 | $3,728.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.92 / $2,008.07 / $2,361.19
| Professional | | $1,218.92 | $2,008.07 | $2,361.19 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $445.78 / $445.78 / $445.78
| Professional | 80 | $445.78 | $445.78 | $445.78 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $445.78 / $445.78 / $445.78
| Professional | AS | $445.78 | $445.78 | $445.78 |
- 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 |