- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,879.75 / $2,879.75 / $2,879.75
| Facility | | $2,879.75 | $2,879.75 | $2,879.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,852.92 / $4,404.04 / $8,468.42
| Facility | | $2,852.92 | $4,404.04 | $8,468.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,830.27 / $7,271.85 / $10,001.81
| Facility | | $4,830.27 | $7,271.85 | $10,001.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,542.60 / $5,456.78 / $6,263.29
| Professional | | $3,542.60 | $5,456.78 | $6,263.29 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $1,215.20 / $1,215.20 / $1,215.20
| Professional | 80 | $1,215.20 | $1,215.20 | $1,215.20 |
- 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 |