- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,551.00 / $5,503.00 / $10,651.00
| Facility | | $2,551.00 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,946.00 / $9,472.00 / $17,487.00
| Facility | | $5,946.00 | $9,472.00 | $17,487.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,908.28 / $2,287.35 / $3,205.91
| Facility | | $1,908.28 | $2,287.35 | $3,205.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.57 / $2,490.46 / $3,202.04
| Professional | | $1,746.57 | $2,490.46 | $3,202.04 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $51.75 / $51.75 / $51.75
| Professional | 80 | $51.75 | $51.75 | $51.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.00 / $8,535.00 / $12,740.00
| Facility | | $1,292.00 | $8,535.00 | $12,740.00 |