- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,809.79 / $1,809.79 / $1,809.79
| Facility | | $1,809.79 | $1,809.79 | $1,809.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $3,058.55 / $5,179.52
| Facility | | $2,000.00 | $3,058.55 | $5,179.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,008.86 / $4,738.99 / $5,874.29
| Facility | | $3,008.86 | $4,738.99 | $5,874.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,420.53 / $3,221.27 / $3,724.20
| Professional | | $2,420.53 | $3,221.27 | $3,724.20 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $720.27 / $720.27 / $720.27
| Professional | 80 | $720.27 | $720.27 | $720.27 |
- 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 |