- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $2,951.21 / $8,511.38
| Facility | | $630.96 | $2,951.21 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,888.44 / $13,489.63
| Facility | | $2,238.72 | $5,888.44 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,230.27 / $3,467.37
| Facility | | $588.84 | $1,230.27 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | 22 | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,981.07 / $10,000.00
| Facility | | $1,047.13 | $3,981.07 | $10,000.00 |