- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,857.17 / $1,857.17 / $1,857.17
| Facility | | $1,857.17 | $1,857.17 | $1,857.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $3,138.62 / $5,047.74
| Facility | | $2,000.00 | $3,138.62 | $5,047.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,372.00 / $4,196.54 / $5,733.51
| Facility | | $3,372.00 | $4,196.54 | $5,733.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,357.39 / $3,123.54 / $3,561.18
| Professional | | $2,357.39 | $3,123.54 | $3,561.18 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $701.48 / $701.48 / $701.48
| Professional | 80 | $701.48 | $701.48 | $701.48 |
- 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 |