- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,370.32 / $7,413.10
| Facility | | $1,905.46 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,890.45 / $11,220.18
| Facility | | $1,288.25 | $3,890.45 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,659.59 / $6,165.95
| Facility | | $1,000.00 | $1,659.59 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $165.96 / $165.96 / $165.96
| Facility | AS | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $5,495.41
| Professional | | $1,047.13 | $1,513.56 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $77.62 / $77.62 / $77.62
| Professional | 80 | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $38.90 / $38.90 / $38.90
| Professional | AS | $38.90 | $38.90 | $38.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $7,413.10 / $17,378.01
| Facility | | $1,995.26 | $7,413.10 | $17,378.01 |