- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,552.25 / $3,486.36 / $3,486.36
| Professional | | $2,552.25 | $3,486.36 | $3,486.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20,694.09 / $26,838.03 / $30,263.27
| Facility | | $20,694.09 | $26,838.03 | $30,263.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,394.98 / $3,758.55 / $5,330.39
| Professional | | $3,394.98 | $3,758.55 | $5,330.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,880.46 / $3,977.15 / $6,095.74
| Professional | | $2,880.46 | $3,977.15 | $6,095.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,101.26 / $3,994.17 / $6,127.27
| Professional | | $3,101.26 | $3,994.17 | $6,127.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,552.25 / $3,486.36 / $3,486.36
| Professional | | $2,552.25 | $3,486.36 | $3,486.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,058.21 / $4,095.12 / $5,576.38
| Professional | | $3,058.21 | $4,095.12 | $5,576.38 |