- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.66 / $5,041.00 / $10,651.00
| Facility | | $2,137.66 | $5,041.00 | $10,651.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,350.00 / $15,967.00 / $33,678.00
| Facility | | $9,350.00 | $15,967.00 | $33,678.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,159.25 / $2,874.26 / $3,793.79
| Facility | | $2,159.25 | $2,874.26 | $3,793.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,699.06 / $3,325.25 / $4,275.32
| Professional | | $2,699.06 | $3,325.25 | $4,275.32 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $69.09 / $69.09 / $69.09
| Professional | 80 | $69.09 | $69.09 | $69.09 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $58.73 / $58.73 / $58.73
| Professional | AS | $58.73 | $58.73 | $58.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,408.00 / $7,328.00 / $14,156.00
| Facility | | $2,408.00 | $7,328.00 | $14,156.00 |