- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,791.68 / $2,476.34 / $2,567.46
| Professional | | $1,791.68 | $2,476.34 | $2,567.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,935.87 / $2,373.71 / $2,373.71
| Facility | | $1,935.87 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,017.65 / $2,444.92
| Professional | | $2,017.65 | $2,017.65 | $2,444.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.27 / $2,211.63 / $2,945.88
| Facility | | $860.27 | $2,211.63 | $2,945.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.35 / $2,798.58 / $2,945.88
| Professional | | $1,178.35 | $2,798.58 | $2,945.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $2,174.05 / $2,589.16
| Professional | | $30.00 | $2,174.05 | $2,589.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,579.52 / $2,876.84 / $4,315.26
| Facility | | $2,579.52 | $2,876.84 | $4,315.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.12 / $2,062.12 / $3,093.17
| Professional | | $2,062.12 | $2,062.12 | $3,093.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.05 / $1,332.55 / $2,113.41
| Professional | | $1,232.05 | $1,332.55 | $2,113.41 |