- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $906.05 / $906.05 / $3,073.00
| Facility | | $906.05 | $906.05 | $3,073.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $742.89 / $1,067.16 / $2,217.12
| Facility | | $742.89 | $1,067.16 | $2,217.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,385.54 / $1,821.47 / $2,125.04
| Facility | | $1,385.54 | $1,821.47 | $2,125.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.08 / $1,386.10 / $1,632.78
| Professional | | $910.08 | $1,386.10 | $1,632.78 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $309.49 / $309.49 / $309.49
| Professional | 80 | $309.49 | $309.49 | $309.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,714.00 / $2,714.00 / $4,561.46
| Facility | | $2,714.00 | $2,714.00 | $4,561.46 |