- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $6,025.60
| Professional | | $2,187.76 | $2,691.53 | $6,025.60 |
- 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
- $2,344.23 / $3,715.35 / $5,248.07
| Professional | | $2,344.23 | $3,715.35 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,090.30 / $5,248.07
| Professional | | $2,570.40 | $3,090.30 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,467.37 / $6,456.54
| Professional | | $2,884.03 | $3,467.37 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $7,762.47
| Professional | | $2,238.72 | $3,090.30 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,090.30 / $5,128.61
| Professional | | $2,089.30 | $3,090.30 | $5,128.61 |