- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,515.14 / $17,453.65 / $17,453.65
| Facility | | $1,515.14 | $17,453.65 | $17,453.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.97 / $2,518.89 / $4,123.50
| Facility | | $1,995.97 | $2,518.89 | $4,123.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,809.08 / $4,202.28 / $32,986.06
| Facility | | $2,809.08 | $4,202.28 | $32,986.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,960.43 / $2,686.33 / $3,107.06
| Professional | | $1,960.43 | $2,686.33 | $3,107.06 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $592.74 / $592.74 / $592.74
| Professional | 80 | $592.74 | $592.74 | $592.74 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $592.74 / $592.74 / $592.74
| Professional | AS | $592.74 | $592.74 | $592.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |