- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,285.71 / $2,285.71 / $2,285.71
| Facility | | $2,285.71 | $2,285.71 | $2,285.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.83 / $1,591.33 / $2,546.12
| Professional | | $919.83 | $1,591.33 | $2,546.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,160.08 / $3,447.80 / $3,657.05
| Facility | | $3,160.08 | $3,447.80 | $3,657.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,422.22 / $3,422.22 / $3,422.22
| Professional | | $3,422.22 | $3,422.22 | $3,422.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,050.41
| Facility | | $2,050.41 | $2,050.41 | $2,050.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $4,216.41
| Professional | | $1,496.80 | $1,496.80 | $4,216.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.83 / $2,449.82 / $15,093.28
| Facility | | $919.83 | $2,449.82 | $15,093.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $949.88 / $1,740.50 / $3,883.50
| Professional | | $949.88 | $1,740.50 | $3,883.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.01 / $1,516.52 / $2,195.59
| Professional | | $1,011.01 | $1,516.52 | $2,195.59 |