- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,551.00 / $5,503.00 / $10,651.00
| Facility | | $2,551.00 | $5,503.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,948.00 / $14,105.00 / $28,800.00
| Facility | | $9,948.00 | $14,105.00 | $28,800.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,063.48 / $2,448.21 / $3,466.66
| Facility | | $2,063.48 | $2,448.21 | $3,466.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.62 / $2,693.03 / $3,462.47
| Professional | | $1,888.62 | $2,693.03 | $3,462.47 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $55.96 / $55.96 / $55.96
| Professional | 80 | $55.96 | $55.96 | $55.96 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $47.57 / $47.57 / $47.57
| Professional | AS | $47.57 | $47.57 | $47.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,292.00 / $8,535.00 / $12,740.00
| Facility | | $1,292.00 | $8,535.00 | $12,740.00 |