- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,675.67 / $3,189.00 / $10,651.00
| Facility | | $2,675.67 | $3,189.00 | $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
- $2,702.70 / $3,604.58 / $4,495.13
| Facility | | $2,702.70 | $3,604.58 | $4,495.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,378.38 / $4,162.16 / $5,351.35
| Professional | | $3,378.38 | $4,162.16 | $5,351.35 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $86.49 / $86.49 / $86.49
| Professional | 80 | $86.49 | $86.49 | $86.49 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $73.51 / $73.51 / $73.51
| Professional | AS | $73.51 | $73.51 | $73.51 |
- 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 |