- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $861.80 / $861.80 / $4,338.00
| Facility | | $861.80 | $861.80 | $4,338.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,153.05 / $1,456.44 / $2,536.08
| Facility | | $1,153.05 | $1,456.44 | $2,536.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,463.38 / $2,365.73 / $2,973.12
| Facility | | $1,463.38 | $2,365.73 | $2,973.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,181.32 / $1,593.81 / $1,874.07
| Professional | | $1,181.32 | $1,593.81 | $1,874.07 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $352.48 / $352.48 / $352.48
| Professional | 80 | $352.48 | $352.48 | $352.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |