- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $946.66 / $946.66 / $946.66
| Facility | | $946.66 | $946.66 | $946.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,021.45 / $1,599.86 / $2,768.06
| Facility | | $1,021.45 | $1,599.86 | $2,768.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,581.85 / $2,380.12 / $3,266.16
| Facility | | $1,581.85 | $2,380.12 | $3,266.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,245.07 / $1,778.31 / $2,048.73
| Professional | | $1,245.07 | $1,778.31 | $2,048.73 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $395.20 / $395.20 / $395.20
| Professional | 80 | $395.20 | $395.20 | $395.20 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $395.20 / $395.20 / $395.20
| Professional | AS | $395.20 | $395.20 | $395.20 |
- 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 |