- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,606.45 / $1,653.82
| Facility | | $1,590.54 | $1,606.45 | $1,653.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,670.07
| Professional | | $1,590.54 | $1,590.54 | $1,670.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $3,069.74
| Facility | | $1,590.54 | $1,590.54 | $3,069.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,622.35
| Professional | | $1,590.54 | $1,590.54 | $1,622.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.51 / $1,590.54 / $1,590.54
| Facility | | $1,500.51 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Professional | | $1,590.54 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,908.65
| Professional | | $1,590.54 | $1,590.54 | $1,908.65 |