- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,233.09 / $1,233.09 / $4,338.00
| Facility | | $1,233.09 | $1,233.09 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,195.58 / $1,924.17 / $3,078.06
| Facility | | $1,195.58 | $1,924.17 | $3,078.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,207.48 / $2,883.74 / $3,790.72
| Facility | | $2,207.48 | $2,883.74 | $3,790.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.40 / $2,056.83 / $2,345.01
| Professional | | $1,550.40 | $2,056.83 | $2,345.01 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $461.35 / $461.35 / $461.35
| Professional | 80 | $461.35 | $461.35 | $461.35 |
- 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 |