- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $918.40 / $918.40 / $918.40
| Facility | | $918.40 | $918.40 | $918.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $889.78 / $1,432.63 / $2,293.98
| Facility | | $889.78 | $1,432.63 | $2,293.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,848.64 / $2,324.54 / $2,814.61
| Facility | | $1,848.64 | $2,324.54 | $2,814.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.23 / $1,530.85 / $1,745.34
| Professional | | $1,232.23 | $1,530.85 | $1,745.34 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $384.13 / $384.13 / $384.13
| Professional | 80 | $384.13 | $384.13 | $384.13 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $384.13 / $384.13 / $384.13
| Professional | AS | $384.13 | $384.13 | $384.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.00 / $821.00 / $821.00
| Facility | | $821.00 | $821.00 | $821.00 |