- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,938.28 / $2,938.28 / $2,938.28
| Facility | | $2,938.28 | $2,938.28 | $2,938.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,123.46 / $4,965.68 / $8,603.77
| Facility | | $3,123.46 | $4,965.68 | $8,603.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,916.93 / $7,409.40 / $10,234.37
| Facility | | $4,916.93 | $7,409.40 | $10,234.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,754.16 / $5,546.13 / $6,405.60
| Professional | | $3,754.16 | $5,546.13 | $6,405.60 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $1,237.98 / $1,237.98 / $1,237.98
| Professional | 80 | $1,237.98 | $1,237.98 | $1,237.98 |
- 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 |