- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $4,365.16
| Facility | | $1,819.70 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,754.23 / $5,011.87
| Facility | | $2,344.23 | $2,754.23 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,168.69 / $4,570.88
| Professional | | $3,981.07 | $4,168.69 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $3,715.35
| Professional | | $2,570.40 | $3,235.94 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Professional | 80 | $741.31 | $741.31 | $741.31 |
- 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 |