- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,204.02 / $2,204.02 / $2,204.02
| Facility | | $2,204.02 | $2,204.02 | $2,204.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,093.65 / $3,375.89 / $6,441.58
| Facility | | $2,093.65 | $3,375.89 | $6,441.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,681.90 / $5,541.03 / $7,673.16
| Facility | | $3,681.90 | $5,541.03 | $7,673.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,702.26 / $4,150.17 / $4,806.47
| Professional | | $2,702.26 | $4,150.17 | $4,806.47 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $925.14 / $925.14 / $925.14
| Professional | 80 | $925.14 | $925.14 | $925.14 |
- 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 |