- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.08 / $640.83 / $8,773.59
| Facility | | $67.08 | $640.83 | $8,773.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $843.91 / $1,090.32 / $1,686.60
| Facility | | $843.91 | $1,090.32 | $1,686.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $976.16 / $1,581.97 / $10,763.28
| Facility | | $976.16 | $1,581.97 | $10,763.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $786.77 / $1,071.21 / $1,260.16
| Professional | | $786.77 | $1,071.21 | $1,260.16 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $236.01 / $236.01 / $236.01
| Professional | 80 | $236.01 | $236.01 | $236.01 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $236.01 / $236.01 / $236.01
| Professional | AS | $236.01 | $236.01 | $236.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,143.00 / $3,143.00 / $3,143.00
| Facility | | $3,143.00 | $3,143.00 | $3,143.00 |