- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,419.16 / $1,645.41 / $1,748.25
| Facility | | $1,419.16 | $1,645.41 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.16 / $1,707.11 / $1,748.25
| Professional | | $1,419.16 | $1,707.11 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $832.26 / $832.26 / $1,040.32
| Facility | | $832.26 | $832.26 | $1,040.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,587.01 / $1,713.97 / $1,713.97
| Professional | | $1,587.01 | $1,713.97 | $1,713.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,179.08 / $2,179.08 / $2,179.08
| Facility | | $2,179.08 | $2,179.08 | $2,179.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,179.08 / $2,179.08 / $2,179.08
| Professional | | $2,179.08 | $2,179.08 | $2,179.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,606.12 / $1,654.30 / $1,748.25
| Facility | | $1,606.12 | $1,654.30 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $2,832.17
| Facility | | $1,748.25 | $1,748.25 | $2,832.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,486.01 / $1,748.25 / $1,748.25
| Professional | | $1,486.01 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,816.81 / $1,816.81
| Facility | | $1,748.25 | $1,816.81 | $1,816.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,816.81 / $1,816.81
| Professional | | $1,748.25 | $1,816.81 | $1,816.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $597.00 / $1,654.30 / $1,748.25
| Facility | | $597.00 | $1,654.30 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $2,477.77
| Professional | | $1,713.97 | $1,713.97 | $2,477.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,748.25
| Facility | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $1,816.81
| Professional | | $1,748.25 | $1,748.25 | $1,816.81 |