- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,951.21 / $5,623.41
| Professional | | $2,454.71 | $2,951.21 | $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
- $2,290.87 / $3,890.45 / $5,011.87
| Professional | | $2,290.87 | $3,890.45 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,311.31 / $5,495.41
| Professional | | $2,290.87 | $3,311.31 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,890.45 / $5,495.41
| Professional | | $3,235.94 | $3,890.45 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,388.44 / $6,760.83
| Professional | | $2,511.89 | $3,388.44 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,467.37 / $5,495.41
| Professional | | $2,344.23 | $3,467.37 | $5,495.41 |