- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.46 / $1,216.46 / $4,338.00
| Facility | | $1,216.46 | $1,216.46 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.48 / $2,055.82 / $3,652.48
| Facility | | $1,614.48 | $2,055.82 | $3,652.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,123.71 / $3,354.60 / $4,141.08
| Facility | | $2,123.71 | $3,354.60 | $4,141.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.38 / $2,271.48 / $2,633.53
| Professional | | $1,707.38 | $2,271.48 | $2,633.53 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $508.06 / $508.06 / $508.06
| Professional | 80 | $508.06 | $508.06 | $508.06 |
- 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 |