- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,630.27 / $6,165.95
| Professional | | $2,137.96 | $2,630.27 | $6,165.95 |
- 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 / $3,630.78 / $5,128.61
| Professional | | $2,290.87 | $3,630.78 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,162.28 / $5,128.61
| Professional | | $2,511.89 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,388.44 / $6,456.54
| Professional | | $2,818.38 | $3,388.44 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $7,585.78
| Professional | | $2,290.87 | $3,019.95 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $5,011.87
| Professional | | $2,089.30 | $3,019.95 | $5,011.87 |