- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $3,235.94 / $8,511.38
| Facility | | $512.86 | $3,235.94 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | 22 | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $562.34 / $4,365.16
| Professional | | $263.03 | $562.34 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,981.07 / $10,000.00
| Facility | | $1,513.56 | $3,981.07 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $549.54 / $2,630.27
| Professional | | $288.40 | $549.54 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $457.09 / $776.25 / $9,332.54
| Facility | | $457.09 | $776.25 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | 22 | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $691.83 / $5,370.32
| Professional | | $302.00 | $691.83 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $2,570.40 / $6,025.60
| Facility | | $660.69 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $588.84 / $4,265.80
| Professional | | $263.03 | $588.84 | $4,265.80 |