- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $4,570.88
| Professional | | $2,041.74 | $2,454.71 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25,703.96 / $26,915.35 / $36,307.81
| Facility | | $25,703.96 | $26,915.35 | $36,307.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,311.31 / $4,265.80
| Professional | | $2,041.74 | $3,311.31 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,754.23 / $4,570.88
| Professional | | $2,238.72 | $2,754.23 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,090.30 / $4,365.16
| Professional | | $2,570.40 | $3,090.30 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $5,623.41
| Professional | | $2,089.30 | $2,884.03 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,951.21 / $4,570.88
| Professional | | $2,041.74 | $2,951.21 | $4,570.88 |