- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,388.44 / $5,754.40
| Professional | | $2,570.40 | $3,388.44 | $5,754.40 |
- 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
- $2,511.89 / $4,073.80 / $5,370.32
| Professional | | $2,511.89 | $4,073.80 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,388.44 / $5,754.40
| Professional | | $2,137.96 | $3,388.44 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,801.89 / $5,370.32
| Professional | | $3,162.28 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $6,918.31
| Professional | | $2,630.27 | $3,630.78 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,801.89 / $5,623.41
| Professional | | $2,511.89 | $3,801.89 | $5,623.41 |