- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $850.91 / $850.91 / $850.91
| Facility | | $850.91 | $850.91 | $850.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.66 / $1,182.58 / $2,279.77
| Facility | | $1,000.66 | $1,182.58 | $2,279.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,297.68 / $2,064.48 / $2,669.65
| Facility | | $1,297.68 | $2,064.48 | $2,669.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.93 / $1,467.91 / $1,678.06
| Professional | | $1,085.93 | $1,467.91 | $1,678.06 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $323.14 / $323.14 / $323.14
| Professional | 80 | $323.14 | $323.14 | $323.14 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $323.14 / $323.14 / $323.14
| Professional | AS | $323.14 | $323.14 | $323.14 |
- 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 |