- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,296.73 / $1,296.73 / $1,296.73
| Facility | | $1,296.73 | $1,296.73 | $1,296.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,411.51 / $2,191.46 / $3,781.75
| Facility | | $1,411.51 | $2,191.46 | $3,781.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,161.03 / $3,250.20 / $4,506.07
| Facility | | $2,161.03 | $3,250.20 | $4,506.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.40 / $2,436.26 / $2,831.48
| Professional | | $1,794.40 | $2,436.26 | $2,831.48 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $541.65 / $541.65 / $541.65
| Professional | 80 | $541.65 | $541.65 | $541.65 |
- 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 |