- 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
- $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
- $2,264.37 / $2,665.66 / $3,804.14
| Facility | | $2,264.37 | $2,665.66 | $3,804.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,072.46 / $2,955.18 / $3,799.52
| Professional | | $2,072.46 | $2,955.18 | $3,799.52 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $61.41 / $61.41 / $61.41
| Professional | 80 | $61.41 | $61.41 | $61.41 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $52.20 / $52.20 / $52.20
| Professional | AS | $52.20 | $52.20 | $52.20 |
- 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 |