- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,757.06 / $5,503.00 / $10,651.00
| Facility | | $2,757.06 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,434.00 / $5,936.00 / $26,117.75
| Facility | | $3,434.00 | $5,936.00 | $26,117.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $713.64 / $913.34 / $1,280.91
| Facility | | $713.64 | $913.34 | $1,280.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.23 / $1,059.85 / $1,413.14
| Professional | | $777.23 | $1,059.85 | $1,413.14 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $22.61 / $22.61 / $22.61
| Professional | 80 | $22.61 | $22.61 | $22.61 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $19.22 / $19.22 / $19.22
| Professional | AS | $19.22 | $19.22 | $19.22 |
- 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 |