- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $984.81 / $7,214.25 / $7,444.22
| Facility | | $984.81 | $7,214.25 | $7,444.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,294.65 / $1,671.27 / $2,610.23
| Facility | | $1,294.65 | $1,671.27 | $2,610.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,501.25 / $2,439.23 / $20,720.43
| Facility | | $1,501.25 | $2,439.23 | $20,720.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.11 / $1,671.15 / $1,965.93
| Professional | | $1,233.11 | $1,671.15 | $1,965.93 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $370.88 / $370.88 / $370.88
| Professional | 80 | $370.88 | $370.88 | $370.88 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $370.88 / $370.88 / $370.88
| Professional | AS | $370.88 | $370.88 | $370.88 |
- 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 |