- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $866.94 / $866.94 / $866.94
| Facility | | $866.94 | $866.94 | $866.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $828.08 / $1,357.61 / $2,212.17
| Facility | | $828.08 | $1,357.61 | $2,212.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,534.00 / $1,891.34 / $2,592.48
| Facility | | $1,534.00 | $1,891.34 | $2,592.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.65 / $1,422.07 / $1,630.19
| Professional | | $1,055.65 | $1,422.07 | $1,630.19 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $314.13 / $314.13 / $314.13
| Professional | 80 | $314.13 | $314.13 | $314.13 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $314.13 / $314.13 / $314.13
| Professional | AS | $314.13 | $314.13 | $314.13 |
- 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 |