- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $6,760.83 / $7,413.10
| Facility | | $5,888.44 | $6,760.83 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $2,454.71
| Professional | | $1,698.24 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,348.96 / $2,041.74
| Professional | | $831.76 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $616.60 / $812.83
| Professional | | $575.44 | $616.60 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $3,311.31 / $4,365.16
| Facility | | $436.52 | $3,311.31 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $549.54 / $741.31
| Professional | | $398.11 | $549.54 | $741.31 |