- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,128.61 / $7,413.10
| Facility | | $2,570.40 | $5,128.61 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,801.89 / $7,244.36
| Facility | | $1,479.11 | $3,801.89 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $2,454.71
| Professional | | $977.24 | $1,230.27 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- 22
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | 22 | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $72.44 / $72.44 / $72.44
| Professional | 80 | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- AS
- Low / Median / High Price
- $36.31 / $36.31 / $36.31
| Professional | AS | $36.31 | $36.31 | $36.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $6,918.31 / $12,022.64
| Facility | | $1,737.80 | $6,918.31 | $12,022.64 |