- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,365.16 / $7,413.10
| Facility | | $2,187.76 | $4,365.16 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22,387.21 / $45,708.82 / $51,286.14
| Facility | | $22,387.21 | $45,708.82 | $51,286.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $23,988.33 / $23,988.33 / $23,988.33
| Facility | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $295.12 / $1,230.27
| Professional | | $223.87 | $295.12 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $21.88 / $21.88 / $21.88
| Professional | 80 | $21.88 | $21.88 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $10.96 / $10.96 / $10.96
| Professional | AS | $10.96 | $10.96 | $10.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $1,513.56 / $2,511.89
| Facility | | $213.80 | $1,513.56 | $2,511.89 |