- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $4,365.16 / $5,623.41
| Facility | | $1,288.25 | $4,365.16 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,995.26 / $3,715.35
| Facility | | $1,698.24 | $1,995.26 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $3,235.94
| Professional | | $2,884.03 | $3,019.95 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $2,691.53
| Professional | | $1,819.70 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $537.03 / $537.03 / $537.03
| Professional | 80 | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $5,370.32
| Facility | | $5,370.32 | $5,370.32 | $5,370.32 |