- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $996.94 / $996.94 / $996.94
| Facility | | $996.94 | $996.94 | $996.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,049.34 / $1,684.83 / $2,886.23
| Facility | | $1,049.34 | $1,684.83 | $2,886.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.74 / $2,489.54 / $3,331.86
| Facility | | $1,659.74 | $2,489.54 | $3,331.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.02 / $1,827.05 / $2,103.07
| Professional | | $1,314.02 | $1,827.05 | $2,103.07 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $404.98 / $404.98 / $404.98
| Professional | 80 | $404.98 | $404.98 | $404.98 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $404.98 / $404.98 / $404.98
| Professional | AS | $404.98 | $404.98 | $404.98 |
- 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 |