- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,784.54 / $1,784.54 / $1,784.54
| Facility | | $1,784.54 | $1,784.54 | $1,784.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,894.99 / $3,015.87 / $5,240.46
| Facility | | $1,894.99 | $3,015.87 | $5,240.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.62 / $4,500.76 / $6,077.64
| Facility | | $3,001.62 | $4,500.76 | $6,077.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,210.21 / $3,332.34 / $3,799.24
| Professional | | $2,210.21 | $3,332.34 | $3,799.24 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $738.67 / $738.67 / $738.67
| Professional | 80 | $738.67 | $738.67 | $738.67 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $738.67 / $738.67 / $738.67
| Professional | AS | $738.67 | $738.67 | $738.67 |
- 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 |