- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $5,370.32 / $7,413.10
| Facility | | $2,754.23 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $2,238.72 / $4,786.30
| Facility | | $691.83 | $2,238.72 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $707.95 / $1,348.96
| Facility | | $512.86 | $707.95 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $316.23 / $1,230.27
| Professional | | $239.88 | $316.23 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 22
- Low / Median / High Price
- $724.44 / $724.44 / $933.25
| Professional | 22 | $724.44 | $724.44 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $2,454.71 / $5,248.07
| Facility | | $524.81 | $2,454.71 | $5,248.07 |