- 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
- $1,183.47 / $1,454.26 / $1,988.23
| Facility | | $1,183.47 | $1,454.26 | $1,988.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.18 / $1,544.53 / $1,985.82
| Professional | | $1,083.18 | $1,544.53 | $1,985.82 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $32.09 / $32.09 / $32.09
| Professional | 80 | $32.09 | $32.09 | $32.09 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $27.28 / $27.28 / $27.28
| Professional | AS | $27.28 | $27.28 | $27.28 |
- 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 |