- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,870.05 / $4,366.64 / $4,375.37
| Professional | | $2,870.05 | $4,366.64 | $4,375.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.10 / $2,481.10 / $3,299.01
| Facility | | $2,481.10 | $2,481.10 | $3,299.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.20 / $2,481.10 / $2,909.47
| Professional | | $1,811.20 | $2,481.10 | $2,909.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,270.53 / $3,665.57 / $5,194.60
| Facility | | $1,270.53 | $3,665.57 | $5,194.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,675.14 / $4,934.88 / $5,194.60
| Professional | | $4,675.14 | $4,934.88 | $5,194.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $3,833.62 / $4,565.57
| Professional | | $30.00 | $3,833.62 | $4,565.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,548.58 / $5,072.85 / $7,609.29
| Facility | | $4,548.58 | $5,072.85 | $7,609.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,636.23 / $3,636.23 / $5,454.34
| Professional | | $3,636.23 | $3,636.23 | $5,454.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3.14 / $2,952.05 / $3,032.69
| Facility | | $3.14 | $2,952.05 | $3,032.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.61 / $1,968.04 / $3,470.89
| Professional | | $1,819.61 | $1,968.04 | $3,470.89 |