- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $952.84 / $11,832.15 / $11,832.15
| Facility | | $952.84 | $11,832.15 | $11,832.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,255.09 / $1,631.70 / $2,546.60
| Facility | | $1,255.09 | $1,631.70 | $2,546.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,767.83 / $2,549.02 / $34,957.40
| Facility | | $1,767.83 | $2,549.02 | $34,957.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.15 / $1,623.40 / $1,891.54
| Professional | | $1,189.15 | $1,623.40 | $1,891.54 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $356.60 / $356.60 / $356.60
| Professional | 80 | $356.60 | $356.60 | $356.60 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $356.60 / $356.60 / $356.60
| Professional | AS | $356.60 | $356.60 | $356.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,357.00 / $5,357.00 / $5,357.00
| Facility | | $5,357.00 | $5,357.00 | $5,357.00 |