- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $737.03 / $737.03 / $737.03
| Facility | | $737.03 | $737.03 | $737.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.03 / $820.54 / $7,307.33
| Professional | | $737.03 | $820.54 | $7,307.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.63 / $1,665.63 / $1,665.63
| Facility | | $1,665.63 | $1,665.63 | $1,665.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.91 / $1,665.63 / $1,715.60
| Professional | | $1,215.91 | $1,665.63 | $1,715.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.27 / $1,923.03 / $2,499.93
| Professional | | $1,192.27 | $1,923.03 | $2,499.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,306.60 / $2,572.46 / $2,572.46
| Facility | | $2,306.60 | $2,572.46 | $2,572.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,464.85 / $1,843.94 / $2,765.91
| Professional | | $1,464.85 | $1,843.94 | $2,765.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.81 / $1,141.66 / $1,637.85
| Professional | | $1,030.81 | $1,141.66 | $1,637.85 |