- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,714.53 / $1,714.53 / $1,714.53
| Facility | | $1,714.53 | $1,714.53 | $1,714.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,826.52 / $2,627.78 / $5,010.71
| Facility | | $1,826.52 | $2,627.78 | $5,010.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,863.04 / $4,305.60 / $5,967.11
| Facility | | $2,863.04 | $4,305.60 | $5,967.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,140.33 / $3,226.49 / $3,746.84
| Professional | | $2,140.33 | $3,226.49 | $3,746.84 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $718.21 / $718.21 / $718.21
| Professional | 80 | $718.21 | $718.21 | $718.21 |
- 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 |