- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,590.54
| Facility | | $1,590.54 | $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
- $127.13 / $127.13 / $127.13
| Professional | | $127.13 | $127.13 | $127.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,500.51 / $1,500.51 / $1,590.54
| Facility | | $1,500.51 | $1,500.51 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,025.69
| Professional | | $1,590.54 | $1,590.54 | $2,025.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.96 / $1,351.96 / $2,590.69
| Professional | | $1,351.96 | $1,351.96 | $2,590.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,577.92
| Professional | | $1,590.54 | $1,590.54 | $2,577.92 |