- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,781.86 / $1,781.86 / $1,781.86
| Facility | | $1,781.86 | $1,781.86 | $1,781.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,724.40 / $2,782.48 / $4,785.35
| Facility | | $1,724.40 | $2,782.48 | $4,785.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,176.00 / $4,015.07 / $5,469.69
| Facility | | $3,176.00 | $4,015.07 | $5,469.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,138.06 / $2,966.37 / $3,381.99
| Professional | | $2,138.06 | $2,966.37 | $3,381.99 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $669.31 / $669.31 / $669.31
| Professional | 80 | $669.31 | $669.31 | $669.31 |
- 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 |