- 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
- $2,375.80 / $2,817.97 / $3,991.34
| Facility | | $2,375.80 | $2,817.97 | $3,991.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,174.46 / $3,100.62 / $3,986.51
| Professional | | $2,174.46 | $3,100.62 | $3,986.51 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $64.43 / $64.43 / $64.43
| Professional | 80 | $64.43 | $64.43 | $64.43 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $54.76 / $54.76 / $54.76
| Professional | AS | $54.76 | $54.76 | $54.76 |
- 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 |