- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $4,365.16
| Facility | | $2,398.83 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,235.94 / $6,606.93
| Facility | | $2,089.30 | $3,235.94 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,754.40 / $5,754.40 / $6,309.57
| Professional | | $5,754.40 | $5,754.40 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,265.80 / $5,128.61
| Professional | | $2,818.38 | $4,265.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $977.24 / $977.24 / $977.24
| Professional | 80 | $977.24 | $977.24 | $977.24 |
- 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 |