- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $908.05 / $3,988.07 / $15,306.07
| Facility | | $908.05 | $3,988.07 | $15,306.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,093.69 / $1,426.24 / $2,388.55
| Facility | | $1,093.69 | $1,426.24 | $2,388.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,655.67 / $2,429.65 / $8,250.46
| Facility | | $1,655.67 | $2,429.65 | $8,250.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.20 / $1,534.22 / $1,804.85
| Professional | | $1,067.20 | $1,534.22 | $1,804.85 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $336.52 / $336.52 / $336.52
| Professional | 80 | $336.52 | $336.52 | $336.52 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $336.52 / $336.52 / $336.52
| Professional | AS | $336.52 | $336.52 | $336.52 |
- 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 |