- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,523.75 / $1,966.75 / $2,830.96
| Professional | | $1,523.75 | $1,966.75 | $2,830.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,254.90 / $2,254.90 / $2,387.82
| Facility | | $2,254.90 | $2,254.90 | $2,387.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,916.67 / $2,254.90 / $3,052.83
| Professional | | $1,916.67 | $2,254.90 | $3,052.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99,999.99 / $99,999.99 / $99,999.99
| Facility | | $99,999.99 | $99,999.99 | $99,999.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,545.53 / $2,952.95 / $99,999.99
| Professional | | $2,545.53 | $2,952.95 | $99,999.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,545.49 / $2,247.99 / $2,809.99
| Professional | | $1,545.49 | $2,247.99 | $2,809.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,175.88 / $1,392.95 / $2,209.83
| Professional | | $1,175.88 | $1,392.95 | $2,209.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,655.12 / $2,655.12 / $2,655.12
| Professional | | $2,655.12 | $2,655.12 | $2,655.12 |