- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4.20 / $5,496.04 / $47,504.63
| Facility | | $4.20 | $5,496.04 | $47,504.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.63 / $1,381.87 / $1,994.00
| Professional | | $984.63 | $1,381.87 | $1,994.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.79 / $1,125.63 / $2,093.71
| Professional | | $956.79 | $1,125.63 | $2,093.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.41 / $1,797.50 / $2,323.73
| Professional | | $1,263.41 | $1,797.50 | $2,323.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,685.00 / $8,200.00 / $27,485.00
| Facility | | $4,685.00 | $8,200.00 | $27,485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.83 / $1,610.73 / $2,471.60
| Professional | | $1,158.83 | $1,610.73 | $2,471.60 |