- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $1,748.25 / $5,192.30
| Facility | | $1,748.25 | $1,748.25 | $5,192.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,748.25 / $1,748.25
| Professional | | $1,645.41 | $1,748.25 | $1,748.25 |
- 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 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $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
- $573.53 / $2,079.80 / $3,181.42
| Facility | | $573.53 | $2,079.80 | $3,181.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,748.25 / $2,409.92 / $5,192.30
| Facility | | $1,748.25 | $2,409.92 | $5,192.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.41 / $1,748.25 / $2,220.28
| Professional | | $1,645.41 | $1,748.25 | $2,220.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,087.46 / $3,000.00 / $4,646.43
| Professional | | $2,087.46 | $3,000.00 | $4,646.43 |
- 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 / $1,748.25
| Professional | | $1,748.25 | $1,748.25 | $1,748.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,742.49 / $1,742.49 / $1,917.07
| Facility | | $1,742.49 | $1,742.49 | $1,917.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,742.49 / $1,742.49 / $1,917.07
| Professional | | $1,742.49 | $1,742.49 | $1,917.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.97 / $1,713.97 / $2,366.98
| Professional | | $1,713.97 | $1,713.97 | $2,366.98 |