- 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
- $1,621.81 / $1,949.84 / $2,344.23
| Professional | | $1,621.81 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,348.96 / $1,905.46
| Professional | | $758.58 | $1,348.96 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $602.56 / $812.83
| Professional | | $575.44 | $602.56 | $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
- $380.19 / $524.81 / $691.83
| Professional | | $380.19 | $524.81 | $691.83 |