- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $954.99 / $4,365.16
| Facility | | $954.99 | $954.99 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $2,754.23
| Facility | | $851.14 | $1,445.44 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,398.83 / $2,511.89
| Professional | | $2,290.87 | $2,398.83 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,041.74
| Professional | | $1,202.26 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Professional | 80 | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Professional | AS | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |