- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $3,715.35 / $9,772.37
| Facility | | $707.95 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,248.07 / $12,022.64
| Facility | | $1,905.46 | $5,248.07 | $12,022.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $812.83 / $2,511.89
| Facility | | $316.23 | $812.83 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Facility | 22 | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,265.80 / $10,000.00
| Facility | | $1,584.89 | $4,265.80 | $10,000.00 |