- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $597.27 / $597.27 / $597.27
| Facility | | $597.27 | $597.27 | $597.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $570.45 / $934.98 / $1,525.76
| Facility | | $570.45 | $934.98 | $1,525.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,032.00 / $1,302.86 / $1,783.26
| Facility | | $1,032.00 | $1,302.86 | $1,783.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $726.98 / $981.12 / $1,123.02
| Professional | | $726.98 | $981.12 | $1,123.02 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $216.32 / $216.32 / $216.32
| Professional | 80 | $216.32 | $216.32 | $216.32 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $216.32 / $216.32 / $216.32
| Professional | AS | $216.32 | $216.32 | $216.32 |
- 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 |