- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,888.44 / $9,549.93
| Facility | | $4,265.80 | $5,888.44 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,801.89 / $6,918.31
| Facility | | $1,380.38 | $3,801.89 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $5,370.32 / $5,888.44
| Facility | | $776.25 | $5,370.32 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,000.00 / $7,762.47
| Professional | | $691.83 | $1,000.00 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $48.98 / $48.98 / $75.86
| Professional | 80 | $48.98 | $48.98 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $6,309.57 / $12,022.64
| Facility | | $1,258.93 | $6,309.57 | $12,022.64 |