- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $772.87 / $772.87 / $772.87
| Facility | | $772.87 | $772.87 | $772.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,024.75 / $1,306.15 / $2,530.37
| Facility | | $1,024.75 | $1,306.15 | $2,530.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,470.86 / $2,125.71 / $2,882.41
| Facility | | $1,470.86 | $2,125.71 | $2,882.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.71 / $1,559.65 / $1,669.65
| Professional | | $1,175.71 | $1,559.65 | $1,669.65 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $351.96 / $351.96 / $351.96
| Professional | 80 | $351.96 | $351.96 | $351.96 |
- 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 |