- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,687.94 / $2,687.94 / $2,687.94
| Facility | | $2,687.94 | $2,687.94 | $2,687.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,565.19 / $4,531.30 / $7,138.89
| Facility | | $3,565.19 | $4,531.30 | $7,138.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,218.14 / $6,303.20 / $8,345.79
| Facility | | $4,218.14 | $6,303.20 | $8,345.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,314.99 / $4,612.59 / $5,261.24
| Professional | | $3,314.99 | $4,612.59 | $5,261.24 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $1,018.44 / $1,018.44 / $1,018.44
| Professional | 80 | $1,018.44 | $1,018.44 | $1,018.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $4,500.00
| Facility | | $4,500.00 | $4,500.00 | $4,500.00 |