- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,495.41 / $5,495.41
| Facility | | $4,365.16 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $2,238.72
| Facility | | $575.44 | $602.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | 22 | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Facility | AS | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $1,995.26
| Professional | | $1,071.52 | $1,412.54 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $416.87 / $1,230.27
| Facility | | $302.00 | $416.87 | $1,230.27 |