- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.10 / $2,355.50 / $2,355.50
| Professional | | $1,528.10 | $2,355.50 | $2,355.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,110.59 / $4,030.05 / $7,470.45
| Facility | | $3,110.59 | $4,030.05 | $7,470.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,055.03 / $2,097.52 / $2,625.68
| Professional | | $2,055.03 | $2,097.52 | $2,625.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,400.00 / $2,400.00 / $2,570.55
| Facility | | $2,400.00 | $2,400.00 | $2,570.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.00 / $1,752.00 / $2,400.00
| Professional | | $1,752.00 | $1,752.00 | $2,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.69 / $2,831.69 / $2,831.69
| Professional | | $2,831.69 | $2,831.69 | $2,831.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,969.26 / $2,355.50 / $2,355.50
| Professional | | $1,969.26 | $2,355.50 | $2,355.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.21 / $1,744.81 / $4,012.53
| Professional | | $1,163.21 | $1,744.81 | $4,012.53 |