- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,032.26 / $2,348.67 / $2,348.67
| Professional | | $2,032.26 | $2,348.67 | $2,348.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,101.56 / $4,018.36 / $7,448.77
| Facility | | $3,101.56 | $4,018.36 | $7,448.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,067.19 / $2,159.28 / $2,618.09
| Professional | | $2,067.19 | $2,159.28 | $2,618.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,375.33 / $2,375.33 / $2,563.11
| Facility | | $2,375.33 | $2,375.33 | $2,563.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.99 / $1,733.99 / $2,375.33
| Professional | | $1,733.99 | $1,733.99 | $2,375.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,823.48 / $2,823.48 / $2,823.48
| Professional | | $2,823.48 | $2,823.48 | $2,823.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.57 / $2,348.67 / $2,348.67
| Professional | | $1,963.57 | $2,348.67 | $2,348.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.83 / $1,739.75 / $4,000.91
| Professional | | $1,159.83 | $1,739.75 | $4,000.91 |