- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,235.94 / $9,549.93
| Facility | | $1,202.26 | $3,235.94 | $9,549.93 |
- 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
- Low / Median / High Price
- $4,570.88 / $9,549.93 / $17,378.01
| Facility | | $4,570.88 | $9,549.93 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $4,677.35
| Professional | | $1,096.48 | $1,548.82 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $12,022.64 / $18,620.87
| Facility | | $8,511.38 | $12,022.64 | $18,620.87 |