- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.07 / $450.07 / $450.07
| Facility | | $450.07 | $450.07 | $450.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $572.54 / $760.62 / $1,257.44
| Facility | | $572.54 | $760.62 | $1,257.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $797.00 / $1,237.72 / $4,555.17
| Facility | | $797.00 | $1,237.72 | $4,555.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.75 / $786.36 / $925.07
| Professional | | $590.75 | $786.36 | $925.07 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $175.79 / $175.79 / $175.79
| Professional | 80 | $175.79 | $175.79 | $175.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |