- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,061.01 / $2,061.01 / $2,061.01
| Facility | | $2,061.01 | $2,061.01 | $2,061.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,307.57 / $2,979.94 / $5,832.30
| Facility | | $2,307.57 | $2,979.94 | $5,832.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,275.98 / $5,332.21 / $7,057.90
| Facility | | $3,275.98 | $5,332.21 | $7,057.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,892.36 / $3,916.93 / $4,506.95
| Professional | | $2,892.36 | $3,916.93 | $4,506.95 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $860.67 / $860.67 / $860.67
| Professional | 80 | $860.67 | $860.67 | $860.67 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $860.67 / $860.67 / $860.67
| Professional | AS | $860.67 | $860.67 | $860.67 |
- 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 |