- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,723.21 / $5,503.00 / $10,651.00
| Facility | | $2,723.21 | $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
- $2,461.64 / $3,170.78 / $4,574.99
| Facility | | $2,461.64 | $3,170.78 | $4,574.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,492.42 / $3,554.03 / $4,569.46
| Professional | | $2,492.42 | $3,554.03 | $4,569.46 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $73.84 / $73.84 / $73.84
| Professional | 80 | $73.84 | $73.84 | $73.84 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $62.77 / $62.77 / $62.77
| Professional | AS | $62.77 | $62.77 | $62.77 |
- 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 |