- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $6,309.57
| Professional | | $2,290.87 | $2,818.38 | $6,309.57 |
- 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
- $2,398.83 / $3,890.45 / $5,370.32
| Professional | | $2,398.83 | $3,890.45 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,235.94 / $5,370.32
| Professional | | $2,630.27 | $3,235.94 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,548.13 / $6,760.83
| Professional | | $3,019.95 | $3,548.13 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $8,128.31
| Professional | | $2,398.83 | $3,235.94 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $5,370.32
| Professional | | $2,187.76 | $3,162.28 | $5,370.32 |