- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $6,309.57
| Professional | | $2,570.40 | $3,311.31 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,379.62 / $22,387.21 / $30,199.52
| Facility | | $21,379.62 | $22,387.21 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,073.80 / $5,495.41
| Professional | | $2,454.71 | $4,073.80 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $6,165.95
| Professional | | $2,454.71 | $3,715.35 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $5,623.41
| Professional | | $3,019.95 | $3,715.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,890.45 / $7,762.47
| Professional | | $2,570.40 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,073.80 / $5,623.41
| Professional | | $2,691.53 | $4,073.80 | $5,623.41 |