- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,570.88 / $7,413.10
| Facility | | $1,202.26 | $4,570.88 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $3,019.95 / $8,511.38
| Facility | | $1,071.52 | $3,019.95 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $1,412.54
| Professional | | $645.65 | $794.33 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $45.71 / $45.71 / $45.71
| Professional | 80 | $45.71 | $45.71 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $7,762.47 / $17,378.01
| Facility | | $1,995.26 | $7,762.47 | $17,378.01 |