- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,698.24
| Facility | | $575.44 | $602.56 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | 22 | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- AS
- Low / Median / High Price
- $169.82 / $169.82 / $169.82
| Facility | AS | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $1,513.56
| Professional | | $812.83 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $416.87 / $1,096.48
| Facility | | $302.00 | $416.87 | $1,096.48 |