- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.43 / $751.43 / $751.43
| Facility | | $751.43 | $751.43 | $751.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,005.33 / $1,351.84 / $2,388.42
| Facility | | $1,005.33 | $1,351.84 | $2,388.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,308.40 / $2,009.38 / $2,034.84
| Facility | | $1,308.40 | $2,009.38 | $2,034.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.69 / $1,543.90 / $1,760.21
| Professional | | $1,138.69 | $1,543.90 | $1,760.21 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Professional | 80 | $338.84 | $338.84 | $338.84 |
- 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 |