- 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
- $5,946.00 / $9,278.00 / $17,183.00
| Facility | | $5,946.00 | $9,278.00 | $17,183.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,829.67 / $2,195.98 / $3,073.85
| Facility | | $1,829.67 | $2,195.98 | $3,073.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.62 / $2,387.88 / $3,070.13
| Professional | | $1,674.62 | $2,387.88 | $3,070.13 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $49.62 / $49.62 / $49.62
| Professional | 80 | $49.62 | $49.62 | $49.62 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $42.18 / $42.18 / $42.18
| Professional | AS | $42.18 | $42.18 | $42.18 |
- 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 |