- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.06 / $149.06 / $149.06
| Facility | | $149.06 | $149.06 | $149.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.07 / $206.91 / $412.91
| Facility | | $175.07 | $206.91 | $412.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.04 / $365.94 / $480.78
| Facility | | $234.04 | $365.94 | $480.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.38 / $261.98 / $296.93
| Professional | | $196.38 | $261.98 | $296.93 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $58.42 / $58.42 / $58.42
| Professional | 80 | $58.42 | $58.42 | $58.42 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $58.42 / $58.42 / $58.42
| Professional | AS | $58.42 | $58.42 | $58.42 |
- 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 |