- 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 / $1,606.45
| Professional | | $1,590.54 | $1,590.54 | $1,606.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.95 / $1,590.54 / $1,590.54
| Professional | | $1,351.95 | $1,590.54 | $1,590.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $2,226.76 / $2,544.86
| Facility | | $1,590.54 | $2,226.76 | $2,544.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,749.59 / $2,306.28
| Professional | | $1,590.54 | $1,749.59 | $2,306.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $2,550.00 / $2,550.00
| Facility | | $1,590.54 | $2,550.00 | $2,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,416.21
| Professional | | $1,590.54 | $1,590.54 | $2,416.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.82 / $1,853.66 / $2,409.76
| Professional | | $1,653.82 | $1,853.66 | $2,409.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,736.51
| Professional | | $1,590.54 | $1,590.54 | $1,736.51 |