- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,250.26 / $2,250.26 / $4,338.00
| Facility | | $2,250.26 | $2,250.26 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,199.90 / $3,526.20 / $5,643.64
| Facility | | $2,199.90 | $3,526.20 | $5,643.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,115.22 / $5,301.31 / $6,967.17
| Facility | | $4,115.22 | $5,301.31 | $6,967.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,892.36 / $3,781.72 / $4,311.59
| Professional | | $2,892.36 | $3,781.72 | $4,311.59 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $860.67 / $860.67 / $860.67
| Professional | 80 | $860.67 | $860.67 | $860.67 |
- 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 |