- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $985.80 / $985.80 / $985.80
| Facility | | $985.80 | $985.80 | $985.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,268.84 / $1,666.00 / $2,782.15
| Facility | | $1,268.84 | $1,666.00 | $2,782.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,612.95 / $2,577.53 / $3,225.48
| Facility | | $1,612.95 | $2,577.53 | $3,225.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.25 / $1,745.93 / $2,053.91
| Professional | | $1,311.25 | $1,745.93 | $2,053.91 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $390.18 / $390.18 / $390.18
| Professional | 80 | $390.18 | $390.18 | $390.18 |
- 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 |