- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,168.69 / $6,918.31
| Facility | | $3,715.35 | $4,168.69 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $1,096.48
| Facility | | $575.44 | $602.56 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | 22 | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $691.83 / $1,000.00
| Professional | | $537.03 | $691.83 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $3,235.94
| Facility | | $1,023.29 | $1,445.44 | $3,235.94 |