- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $4,365.16
| Facility | | $1,778.28 | $1,778.28 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,630.27 / $4,466.84
| Facility | | $2,187.76 | $2,630.27 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,981.07
| Professional | | $3,801.89 | $3,801.89 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $3,388.44
| Professional | | $2,187.76 | $2,951.21 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $691.83 / $691.83 / $691.83
| Professional | 80 | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |