- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,715.73 / $1,715.73 / $1,715.73
| Facility | | $1,715.73 | $1,715.73 | $1,715.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,899.58 / $4,662.89
| Facility | | $2,000.00 | $2,899.58 | $4,662.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,102.00 / $3,869.84 / $5,286.12
| Facility | | $3,102.00 | $3,869.84 | $5,286.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,171.86 / $2,875.02 / $3,277.84
| Professional | | $2,171.86 | $2,875.02 | $3,277.84 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $646.27 / $646.27 / $646.27
| Professional | 80 | $646.27 | $646.27 | $646.27 |
- 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 |