- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,744.43 / $1,863.02 / $2,303.00
| Facility | | $1,744.43 | $1,863.02 | $2,303.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,754.43 / $1,863.02 / $2,086.44
| Professional | | $1,754.43 | $1,863.02 | $2,086.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.97 / $1,757.29 / $1,757.29
| Professional | | $37.97 | $1,757.29 | $1,757.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,219.23 / $3,227.98 / $3,668.23
| Facility | | $2,219.23 | $3,227.98 | $3,668.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.92 / $2,825.47 / $4,036.38
| Professional | | $2,320.92 | $2,825.47 | $4,036.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,373.25 / $2,373.25 / $2,984.18
| Professional | | $2,373.25 | $2,373.25 | $2,984.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,000.00 / $3,000.00 / $3,000.00
| Professional | | $3,000.00 | $3,000.00 | $3,000.00 |