- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,570.40 / $2,570.40
| Facility | | $1,412.54 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Facility | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $4,073.80 / $4,073.80
| Facility | | $34.67 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | 22 | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | AS | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |