- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,741.12 / $2,406.46 / $2,716.74
| Professional | | $1,741.12 | $2,406.46 | $2,716.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,787.17 / $1,787.17 / $2,048.41
| Facility | | $1,787.17 | $1,787.17 | $2,048.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,304.63 / $1,304.63 / $2,631.74
| Professional | | $1,304.63 | $1,304.63 | $2,631.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $789.12 / $2,151.39 / $2,862.78
| Facility | | $789.12 | $2,151.39 | $2,862.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,576.50 / $2,719.64 / $2,862.78
| Professional | | $2,576.50 | $2,719.64 | $2,862.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,112.73 / $2,516.11
| Professional | | $30.00 | $2,112.73 | $2,516.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,506.73 / $2,795.68 / $4,193.52
| Facility | | $2,506.73 | $2,795.68 | $4,193.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,003.95 / $2,003.95 / $3,005.92
| Professional | | $2,003.95 | $2,003.95 | $3,005.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.21 / $1,448.21 / $1,448.21
| Facility | | $1,448.21 | $1,448.21 | $1,448.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.16 / $1,222.33 / $1,912.82
| Professional | | $1,130.16 | $1,222.33 | $1,912.82 |