- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,235.49 / $1,235.49 / $1,235.49
| Facility | | $1,235.49 | $1,235.49 | $1,235.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.27 / $2,087.98 / $3,518.78
| Facility | | $1,590.27 | $2,087.98 | $3,518.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.33 / $3,230.30 / $3,996.13
| Facility | | $2,041.33 | $3,230.30 | $3,996.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,644.68 / $2,194.90 / $2,541.67
| Professional | | $1,644.68 | $2,194.90 | $2,541.67 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $489.40 / $489.40 / $489.40
| Professional | 80 | $489.40 | $489.40 | $489.40 |
- 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 |