- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $4,365.16
| Facility | | $1,288.25 | $1,288.25 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,995.26 / $3,801.89
| Facility | | $1,174.90 | $1,995.26 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,235.94 / $3,467.37
| Professional | | $3,162.28 | $3,235.94 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,344.23 / $2,818.38
| Professional | | $1,659.59 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | 80 | $562.34 | $562.34 | $562.34 |
- 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 |