- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $4,365.16
| Facility | | $2,187.76 | $2,187.76 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $6,456.54
| Facility | | $1,995.26 | $2,884.03 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,495.41 / $5,888.44
| Professional | | $5,370.32 | $5,495.41 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,981.07 / $4,786.30
| Professional | | $2,754.23 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $954.99 / $954.99 / $954.99
| Professional | 80 | $954.99 | $954.99 | $954.99 |
- 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 |