- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,131.10 / $1,131.10 / $4,338.00
| Facility | | $1,131.10 | $1,131.10 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,457.10 / $1,911.58 / $3,211.84
| Facility | | $1,457.10 | $1,911.58 | $3,211.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,866.26 / $2,959.11 / $3,668.70
| Facility | | $1,866.26 | $2,959.11 | $3,668.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,481.53 / $2,003.43 / $2,331.42
| Professional | | $1,481.53 | $2,003.43 | $2,331.42 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $448.48 / $448.48 / $448.48
| Professional | 80 | $448.48 | $448.48 | $448.48 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $448.48 / $448.48 / $448.48
| Professional | AS | $448.48 | $448.48 | $448.48 |
- 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 |