- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,133.00 / $5,503.00 / $10,651.00
| Facility | | $3,133.00 | $5,503.00 | $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
- $3,361.04 / $4,383.52 / $6,273.94
| Facility | | $3,361.04 | $4,383.52 | $6,273.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,418.01 / $4,873.82 / $6,266.34
| Professional | | $3,418.01 | $4,873.82 | $6,266.34 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $101.27 / $101.27 / $101.27
| Professional | 80 | $101.27 | $101.27 | $101.27 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $86.08 / $86.08 / $86.08
| Professional | AS | $86.08 | $86.08 | $86.08 |
- 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 |