- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,168.33 / $2,168.33 / $3,511.00
| Facility | | $2,168.33 | $2,168.33 | $3,511.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,087.94 / $3,455.93 / $6,124.50
| Facility | | $2,087.94 | $3,455.93 | $6,124.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,526.14 / $5,252.11 / $7,044.35
| Facility | | $3,526.14 | $5,252.11 | $7,044.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,869.52 / $3,880.38 / $4,428.68
| Professional | | $2,869.52 | $3,880.38 | $4,428.68 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $852.04 / $852.04 / $852.04
| Professional | 80 | $852.04 | $852.04 | $852.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |