- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $4,365.16
| Facility | | $1,096.48 | $1,096.48 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $3,162.28
| Facility | | $1,000.00 | $1,659.59 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,754.23 / $2,951.21
| Professional | | $2,691.53 | $2,754.23 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $2,398.83
| Professional | | $1,380.38 | $1,995.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Professional | 80 | $467.74 | $467.74 | $467.74 |
- 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 |