- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $940.95 / $940.95 / $940.95
| Facility | | $940.95 | $940.95 | $940.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,008.48 / $1,609.22 / $2,738.46
| Facility | | $1,008.48 | $1,609.22 | $2,738.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,568.87 / $2,356.32 / $3,218.18
| Facility | | $1,568.87 | $2,356.32 | $3,218.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.83 / $1,752.78 / $2,022.21
| Professional | | $1,182.83 | $1,752.78 | $2,022.21 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $389.15 / $389.15 / $389.15
| Professional | 80 | $389.15 | $389.15 | $389.15 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $389.15 / $389.15 / $389.15
| Professional | AS | $389.15 | $389.15 | $389.15 |
- 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 |