- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,370.32 / $9,549.93
| Facility | | $2,398.83 | $5,370.32 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,365.16 / $10,000.00
| Facility | | $1,513.56 | $4,365.16 | $10,000.00 |
- 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
- $1,071.52 / $1,380.38 / $3,630.78
| Professional | | $1,071.52 | $1,380.38 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- 22
- Low / Median / High Price
- $6,456.54 / $6,456.54 / $6,456.54
| Professional | 22 | $6,456.54 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- 80
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Professional | 80 | $173.78 | $173.78 | $173.78 |
- 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 |