- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,306.85 / $2,306.85 / $2,306.85
| Facility | | $2,306.85 | $2,306.85 | $2,306.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,580.81 / $3,898.58 / $6,519.59
| Facility | | $2,580.81 | $3,898.58 | $6,519.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,662.11 / $5,965.81 / $7,906.76
| Facility | | $3,662.11 | $5,965.81 | $7,906.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.08 / $4,374.71 / $5,040.64
| Professional | | $3,235.08 | $4,374.71 | $5,040.64 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $962.72 / $962.72 / $962.72
| Professional | 80 | $962.72 | $962.72 | $962.72 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $962.72 / $962.72 / $962.72
| Professional | AS | $962.72 | $962.72 | $962.72 |
- 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 |