- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,090.30 / $7,762.47
| Facility | | $645.65 | $3,090.30 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $1,737.80
| Facility | | $794.33 | $933.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,479.11 / $1,513.56
| Professional | | $1,380.38 | $1,479.11 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,122.02 / $1,318.26
| Professional | | $758.58 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Professional | 80 | $251.19 | $251.19 | $251.19 |
- 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 |