- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $6,309.57
| Facility | | $5,128.61 | $5,128.61 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $1,778.28 / $2,041.74
| Facility | | $602.56 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | 22 | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $165.96 / $165.96 / $165.96
| Facility | AS | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $1,479.11
| Professional | | $794.33 | $1,047.13 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,786.30 / $9,772.37
| Facility | | $2,454.71 | $4,786.30 | $9,772.37 |