- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.38 / $2,610.00 / $3,167.67
| Professional | | $1,888.38 | $2,610.00 | $3,167.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,050.41 / $2,050.41 / $2,388.40
| Facility | | $2,050.41 | $2,050.41 | $2,388.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.80 / $1,496.80 / $3,609.74
| Professional | | $1,496.80 | $1,496.80 | $3,609.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $919.83 / $2,378.63 / $3,437.85
| Facility | | $919.83 | $2,378.63 | $3,437.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,794.40 / $2,949.65 / $3,104.89
| Professional | | $2,794.40 | $2,949.65 | $3,104.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,291.40 / $2,728.91
| Professional | | $30.00 | $2,291.40 | $2,728.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,718.75 / $3,032.12 / $4,548.18
| Facility | | $2,718.75 | $3,032.12 | $4,548.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,173.42 / $2,266.57 / $3,260.13
| Professional | | $2,173.42 | $2,266.57 | $3,260.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.35 / $1,424.81 / $2,259.73
| Professional | | $1,317.35 | $1,424.81 | $2,259.73 |