- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,370.32 / $9,549.93
| Facility | | $1,949.84 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,801.89 / $7,413.10
| Facility | | $1,230.27 | $3,801.89 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $4,073.80
| Professional | | $1,202.26 | $1,584.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- 22
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | 22 | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $85.11 / $85.11 / $85.11
| Professional | 80 | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,235.94 / $7,943.28
| Facility | | $602.56 | $3,235.94 | $7,943.28 |