- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,378.71 / $2,378.71 / $2,378.71
| Facility | | $2,378.71 | $2,378.71 | $2,378.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,333.17 / $3,916.82 / $6,655.91
| Facility | | $2,333.17 | $3,916.82 | $6,655.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,813.95 / $5,814.36 / $8,085.10
| Facility | | $3,813.95 | $5,814.36 | $8,085.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,645.91 / $4,290.58 / $5,168.08
| Professional | | $2,645.91 | $4,290.58 | $5,168.08 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $951.00 / $951.00 / $951.00
| Professional | 80 | $951.00 | $951.00 | $951.00 |
- 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 |