- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,370.32 / $9,549.93
| Facility | | $2,454.71 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,888.44 / $12,022.64
| Facility | | $2,238.72 | $5,888.44 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,047.13 / $4,265.80
| Professional | | $870.96 | $1,047.13 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- 22
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | 22 | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $54.95 / $54.95 / $54.95
| Professional | 80 | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $27.54 / $27.54 / $27.54
| Professional | AS | $27.54 | $27.54 | $27.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $7,943.28
| Facility | | $602.56 | $3,235.94 | $7,943.28 |