- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $943.76 / $5,503.00 / $10,651.00
| Facility | | $943.76 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,427.00 / $7,478.00 / $13,989.00
| Facility | | $4,427.00 | $7,478.00 | $13,989.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,261.85 / $2,261.85 / $7,124.94
| Facility | | $2,261.85 | $2,261.85 | $7,124.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $743.73 / $957.50 / $1,264.33
| Facility | | $743.73 | $957.50 | $1,264.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.01 / $1,067.74 / $1,472.74
| Professional | | $810.01 | $1,067.74 | $1,472.74 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $23.56 / $23.56 / $23.56
| Professional | 80 | $23.56 | $23.56 | $23.56 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $20.03 / $20.03 / $20.03
| Professional | AS | $20.03 | $20.03 | $20.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,804.00 / $8,689.00 / $15,722.00
| Facility | | $3,804.00 | $8,689.00 | $15,722.00 |