- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,365.16 / $15,848.93
| Facility | | $1,318.26 | $4,365.16 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,659.59 / $3,467.37
| Facility | | $933.25 | $1,659.59 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,884.03 / $2,884.03
| Professional | | $2,691.53 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,041.74 / $2,398.83
| Professional | | $1,258.93 | $2,041.74 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Professional | 80 | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |