- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.00 / $4,673.00 / $8,817.77
| Facility | | $1,017.00 | $4,673.00 | $8,817.77 |
- Facility/Professional
- Facility
- Modifier
- 22
- Low / Median / High Price
- $2,772.50 / $2,772.50 / $2,772.50
| Facility | 22 | $2,772.50 | $2,772.50 | $2,772.50 |
- Facility/Professional
- Facility
- Modifier
- 52
- Low / Median / High Price
- $677.57 / $677.57 / $2,283.96
| Facility | 52 | $677.57 | $677.57 | $2,283.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.66 / $2,656.05 / $2,656.05
| Professional | | $1,214.66 | $2,656.05 | $2,656.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,840.00 / $10,006.00 / $47,612.00
| Facility | | $7,840.00 | $10,006.00 | $47,612.00 |