- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,356.30 / $5,503.00 / $10,651.00
| Facility | | $2,356.30 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,586.00 / $8,579.00 / $26,117.75
| Facility | | $4,586.00 | $8,579.00 | $26,117.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,505.47 / $1,919.47 / $2,635.00
| Facility | | $1,505.47 | $1,919.47 | $2,635.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,639.63 / $2,235.86 / $2,981.14
| Professional | | $1,639.63 | $2,235.86 | $2,981.14 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $47.70 / $47.70 / $47.70
| Professional | 80 | $47.70 | $47.70 | $47.70 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $40.54 / $40.54 / $40.54
| Professional | AS | $40.54 | $40.54 | $40.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,146.00 / $13,967.00 / $20,534.00
| Facility | | $11,146.00 | $13,967.00 | $20,534.00 |