- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,356.30 / $6,028.00 / $10,651.00
| Facility | | $2,356.30 | $6,028.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,586.00 / $8,579.00 / $37,329.08
| Facility | | $4,586.00 | $8,579.00 | $37,329.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.58 / $1,449.10 / $2,276.55
| Facility | | $1,219.58 | $1,449.10 | $2,276.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,475.84 / $2,012.51 / $2,683.34
| Professional | | $1,475.84 | $2,012.51 | $2,683.34 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $42.93 / $42.93 / $42.93
| Professional | 80 | $42.93 | $42.93 | $42.93 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $36.49 / $36.49 / $36.49
| Professional | AS | $36.49 | $36.49 | $36.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,858.00 / $20,006.00 / $30,333.00
| Facility | | $12,858.00 | $20,006.00 | $30,333.00 |