- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.24 / $1,772.32 / $2,126.78
| Professional | | $1,473.24 | $1,772.32 | $2,126.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,772.32 / $2,215.40 / $2,569.86
| Facility | | $1,772.32 | $2,215.40 | $2,569.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.01 / $1,440.01 / $1,440.01
| Professional | | $1,440.01 | $1,440.01 | $1,440.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.70 / $1,329.24 / $2,281.86
| Professional | | $1,107.70 | $1,329.24 | $2,281.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,523.15 / $10,523.15 / $10,523.15
| Facility | | $10,523.15 | $10,523.15 | $10,523.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,032.69 / $11,032.69 / $16,615.50
| Professional | | $11,032.69 | $11,032.69 | $16,615.50 |