- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $751.32 / $751.32 / $751.32
| Facility | | $751.32 | $751.32 | $751.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.32 / $914.16 / $8,141.04
| Professional | | $751.32 | $914.16 | $8,141.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,823.10 / $1,823.10 / $1,823.10
| Facility | | $1,823.10 | $1,823.10 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,823.10 / $1,877.79
| Professional | | $1,330.86 | $1,823.10 | $1,877.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.10 / $2,080.81 / $2,705.05
| Professional | | $1,290.10 | $2,080.81 | $2,705.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,495.84 / $2,783.52 / $2,783.52
| Facility | | $2,495.84 | $2,783.52 | $2,783.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,585.03 / $1,995.22 / $2,992.84
| Professional | | $1,585.03 | $1,995.22 | $2,992.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.80 / $1,163.79 / $1,669.61
| Professional | | $1,050.80 | $1,163.79 | $1,669.61 |