- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,506.00 / $5,503.00 / $10,651.00
| Facility | | $2,506.00 | $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
- $1,693.05 / $2,036.75 / $2,844.32
| Facility | | $1,693.05 | $2,036.75 | $2,844.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,549.57 / $2,209.58 / $2,840.88
| Professional | | $1,549.57 | $2,209.58 | $2,840.88 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $45.91 / $45.91 / $45.91
| Professional | 80 | $45.91 | $45.91 | $45.91 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $39.03 / $39.03 / $39.03
| Professional | AS | $39.03 | $39.03 | $39.03 |
- 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 |