- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $871.44 / $871.44 / $4,338.00
| Facility | | $871.44 | $871.44 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,161.42 / $1,472.73 / $2,519.23
| Facility | | $1,161.42 | $1,472.73 | $2,519.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,457.21 / $2,380.87 / $2,996.08
| Facility | | $1,457.21 | $2,380.87 | $2,996.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.11 / $1,596.91 / $1,878.60
| Professional | | $1,170.11 | $1,596.91 | $1,878.60 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $350.93 / $350.93 / $350.93
| Professional | 80 | $350.93 | $350.93 | $350.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $2,714.00
| Facility | | $2,714.00 | $2,714.00 | $2,714.00 |