- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $4,365.16
| Facility | | $2,691.53 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,466.84 / $7,079.46
| Facility | | $3,548.13 | $4,466.84 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,309.57 / $6,309.57
| Professional | | $5,623.41 | $6,309.57 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,570.88 / $5,248.07
| Professional | | $3,235.94 | $4,570.88 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,047.13
| Professional | 80 | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |