- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $6,760.83 / $19,952.62
| Facility | | $2,290.87 | $6,760.83 | $19,952.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,019.95 / $23,988.33
| Facility | | $1,000.00 | $3,019.95 | $23,988.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $6,918.31 / $9,772.37
| Facility | | $2,238.72 | $6,918.31 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Facility | AS | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,041.74 / $7,244.36
| Professional | | $1,412.54 | $2,041.74 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | 80 | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $52.48 / $52.48 / $52.48
| Professional | AS | $52.48 | $52.48 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $8,912.51 / $23,988.33
| Facility | | $2,290.87 | $8,912.51 | $23,988.33 |