- 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
- $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
- $1,642.95 / $2,150.23 / $2,904.21
| Facility | | $1,642.95 | $2,150.23 | $2,904.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,825.51 / $2,489.33 / $3,319.10
| Professional | | $1,825.51 | $2,489.33 | $3,319.10 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $53.11 / $53.11 / $53.11
| Professional | 80 | $53.11 | $53.11 | $53.11 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $45.14 / $45.14 / $45.14
| Professional | AS | $45.14 | $45.14 | $45.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,506.00 / $8,208.00 / $12,740.00
| Facility | | $2,506.00 | $8,208.00 | $12,740.00 |