- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,434.74 / $1,434.74 / $1,434.74
| Facility | | $1,434.74 | $1,434.74 | $1,434.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.00 / $2,424.71 / $4,160.68
| Facility | | $1,360.00 | $2,424.71 | $4,160.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,377.76 / $3,577.85 / $4,948.24
| Facility | | $2,377.76 | $3,577.85 | $4,948.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,736.82 / $2,674.14 / $3,105.77
| Professional | | $1,736.82 | $2,674.14 | $3,105.77 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $593.64 / $593.64 / $593.64
| Professional | 80 | $593.64 | $593.64 | $593.64 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $593.64 / $593.64 / $593.64
| Professional | AS | $593.64 | $593.64 | $593.64 |
- 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 |