- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,536.71 / $5,428.00 / $10,651.00
| Facility | | $2,536.71 | $5,428.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,990.00 / $19,587.00 / $44,198.00
| Facility | | $10,990.00 | $19,587.00 | $44,198.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,536.71 / $3,023.88 / $4,261.67
| Facility | | $2,536.71 | $3,023.88 | $4,261.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,321.73 / $3,310.63 / $4,256.52
| Professional | | $2,321.73 | $3,310.63 | $4,256.52 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $68.79 / $68.79 / $68.79
| Professional | 80 | $68.79 | $68.79 | $68.79 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $58.47 / $58.47 / $58.47
| Professional | AS | $58.47 | $58.47 | $58.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,506.00 / $8,565.00 / $14,156.00
| Facility | | $2,506.00 | $8,565.00 | $14,156.00 |