- 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
- $3,771.68 / $4,313.32 / $6,336.42
| Facility | | $3,771.68 | $4,313.32 | $6,336.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,452.05 / $4,922.35 / $6,328.75
| Professional | | $3,452.05 | $4,922.35 | $6,328.75 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $102.28 / $102.28 / $102.28
| Professional | 80 | $102.28 | $102.28 | $102.28 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $86.94 / $86.94 / $86.94
| Professional | AS | $86.94 | $86.94 | $86.94 |
- 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 |