- 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
- $1,840.58 / $2,254.79 / $3,092.17
| Facility | | $1,840.58 | $2,254.79 | $3,092.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,684.59 / $2,402.11 / $3,088.42
| Professional | | $1,684.59 | $2,402.11 | $3,088.42 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $49.91 / $49.91 / $49.91
| Professional | 80 | $49.91 | $49.91 | $49.91 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $42.43 / $42.43 / $42.43
| Professional | AS | $42.43 | $42.43 | $42.43 |
- 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 |