- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,907.21 / $1,907.21 / $1,907.21
| Facility | | $1,907.21 | $1,907.21 | $1,907.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,907.21 / $1,907.21 / $5,894.45
| Professional | | $1,907.21 | $1,907.21 | $5,894.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,014.75 / $2,456.21 / $3,044.73
| Professional | | $2,014.75 | $2,456.21 | $3,044.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $591.90 / $3,639.55 / $9,961.62
| Facility | | $591.90 | $3,639.55 | $9,961.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.56 / $2,603.86 / $44,281.65
| Professional | | $1,551.56 | $2,603.86 | $44,281.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,044.73 / $3,446.33 / $9,222.02
| Facility | | $3,044.73 | $3,446.33 | $9,222.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,517.63 / $3,044.73 / $3,958.97
| Professional | | $2,517.63 | $3,044.73 | $3,958.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,422.27 / $3,536.74 / $12,572.68
| Professional | | $1,422.27 | $3,536.74 | $12,572.68 |