- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,611.15 / $3,608.97 / $3,676.88
| Professional | | $2,611.15 | $3,608.97 | $3,676.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,637.76 / $2,637.76 / $2,772.35
| Facility | | $2,637.76 | $2,637.76 | $2,772.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.56 / $2,637.76 / $2,716.89
| Professional | | $1,925.56 | $2,637.76 | $2,716.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,067.70 / $3,223.20 / $4,293.27
| Facility | | $1,067.70 | $3,223.20 | $4,293.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,863.94 / $4,078.61 / $4,293.27
| Professional | | $3,863.94 | $4,078.61 | $4,293.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $3,168.43 / $3,773.39
| Professional | | $30.00 | $3,168.43 | $3,773.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,759.34 / $4,192.64 / $6,288.98
| Facility | | $3,759.34 | $4,192.64 | $6,288.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,005.29 / $3,005.29 / $4,507.93
| Professional | | $3,005.29 | $3,005.29 | $4,507.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.12 / $1,653.86 / $2,868.66
| Professional | | $1,529.12 | $1,653.86 | $2,868.66 |