- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,413.10 / $11,220.18
| Facility | | $2,398.83 | $7,413.10 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $812.83 / $2,089.30
| Professional | | $602.56 | $812.83 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $691.83 / $1,148.15
| Professional | | $512.86 | $691.83 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,023.29 / $1,698.24
| Professional | | $691.83 | $1,023.29 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,073.80 / $6,165.95
| Facility | | $1,819.70 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $933.25 / $1,513.56
| Professional | | $537.03 | $933.25 | $1,513.56 |