- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,506.00 / $3,734.00 / $10,651.00
| Facility | | $2,506.00 | $3,734.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,171.00 / $11,898.00 / $22,154.73
| Facility | | $7,171.00 | $11,898.00 | $22,154.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,356.31 / $1,856.52 / $2,282.26
| Facility | | $1,356.31 | $1,856.52 | $2,282.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,630.19 / $2,008.39 / $2,582.21
| Professional | | $1,630.19 | $2,008.39 | $2,582.21 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $41.73 / $41.73 / $41.73
| Professional | 80 | $41.73 | $41.73 | $41.73 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $35.47 / $35.47 / $35.47
| Professional | AS | $35.47 | $35.47 | $35.47 |
- 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 |