- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,494.35 / $1,494.35 / $4,338.00
| Facility | | $1,494.35 | $1,494.35 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,925.12 / $2,306.16 / $4,204.27
| Facility | | $1,925.12 | $2,306.16 | $4,204.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,418.19 / $3,911.43 / $5,004.55
| Facility | | $2,418.19 | $3,911.43 | $5,004.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,896.28 / $2,707.16 / $3,184.69
| Professional | | $1,896.28 | $2,707.16 | $3,184.69 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $598.27 / $598.27 / $598.27
| Professional | 80 | $598.27 | $598.27 | $598.27 |
- 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 |