- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $784.80 / $784.80 / $784.80
| Facility | | $784.80 | $784.80 | $784.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $818.74 / $1,319.51 / $2,277.62
| Facility | | $818.74 | $1,319.51 | $2,277.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.47 / $1,959.08 / $2,674.87
| Facility | | $1,304.47 | $1,959.08 | $2,674.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.70 / $1,458.62 / $1,680.65
| Professional | | $976.70 | $1,458.62 | $1,680.65 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $323.52 / $323.52 / $323.52
| Professional | 80 | $323.52 | $323.52 | $323.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $323.52 / $323.52 / $323.52
| Professional | AS | $323.52 | $323.52 | $323.52 |
- 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 |