- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,311.31 / $5,623.41
| Professional | | $2,511.89 | $3,311.31 | $5,623.41 |
- 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
- $2,454.71 / $3,981.07 / $5,128.61
| Professional | | $2,454.71 | $3,981.07 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,311.31 / $5,495.41
| Professional | | $2,754.23 | $3,311.31 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,715.35 / $5,248.07
| Professional | | $3,090.30 | $3,715.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $6,918.31
| Professional | | $2,570.40 | $3,311.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,630.78 / $5,495.41
| Professional | | $2,511.89 | $3,630.78 | $5,495.41 |