- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,332.81 / $1,332.81 / $4,338.00
| Facility | | $1,332.81 | $1,332.81 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,090.47 / $1,662.17 / $3,227.67
| Facility | | $1,090.47 | $1,662.17 | $3,227.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,338.98 / $2,869.65 / $3,665.08
| Facility | | $2,338.98 | $2,869.65 | $3,665.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.11 / $2,013.29 / $2,396.76
| Professional | | $1,330.11 | $2,013.29 | $2,396.76 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $452.34 / $452.34 / $452.34
| Professional | 80 | $452.34 | $452.34 | $452.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,500.00 / $4,500.00 / $4,500.00
| Facility | | $4,500.00 | $4,500.00 | $4,500.00 |