- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,586.04 / $4,586.04 / $4,586.04
| Facility | | $4,586.04 | $4,586.04 | $4,586.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.92 / $753.93 / $8,629.41
| Professional | | $473.92 | $753.93 | $8,629.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.42 / $638.15 / $901.65
| Professional | | $542.42 | $638.15 | $901.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.63 / $1,029.11 / $12,342.92
| Professional | | $591.63 | $1,029.11 | $12,342.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.39 / $1,787.43 / $10,601.84
| Professional | | $587.39 | $1,787.43 | $10,601.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,586.04 / $4,586.04 / $4,586.04
| Facility | | $4,586.04 | $4,586.04 | $4,586.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.81 / $753.93 / $8,491.44
| Professional | | $491.81 | $753.93 | $8,491.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,650.17 / $9,258.76 / $12,002.10
| Professional | | $5,650.17 | $9,258.76 | $12,002.10 |