- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $7,943.28
| Facility | | $7,943.28 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $3,090.30
| Facility | | $575.44 | $602.56 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | 22 | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | AS | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,905.46 / $2,691.53
| Professional | | $1,445.44 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $416.87 / $1,230.27
| Facility | | $302.00 | $416.87 | $1,230.27 |