- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,182.22 / $1,182.22 / $1,182.22
| Facility | | $1,182.22 | $1,182.22 | $1,182.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.01 / $1,810.60 / $3,430.12
| Facility | | $1,200.01 | $1,810.60 | $3,430.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,963.33 / $2,953.18 / $4,083.74
| Facility | | $1,963.33 | $2,953.18 | $4,083.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.23 / $2,203.60 / $2,566.90
| Professional | | $1,455.23 | $2,203.60 | $2,566.90 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $490.56 / $490.56 / $490.56
| Professional | 80 | $490.56 | $490.56 | $490.56 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $490.56 / $490.56 / $490.56
| Professional | AS | $490.56 | $490.56 | $490.56 |
- 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 |