- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.83 / $867.83 / $867.83
| Facility | | $867.83 | $867.83 | $867.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $708.02 / $1,078.84 / $1,986.43
| Facility | | $708.02 | $1,078.84 | $1,986.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,507.54 / $1,760.40 / $2,474.66
| Facility | | $1,507.54 | $1,760.40 | $2,474.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.36 / $1,240.47 / $1,555.15
| Professional | | $817.36 | $1,240.47 | $1,555.15 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $277.97 / $277.97 / $277.97
| Professional | 80 | $277.97 | $277.97 | $277.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |