- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,653.82 / $1,653.82 / $1,653.82
| Facility | | $1,653.82 | $1,653.82 | $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
- 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
- $1,590.54 / $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 / $2,025.69
| Professional | | $1,590.54 | $1,590.54 | $2,025.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,351.96 / $1,590.54 / $2,590.69
| Professional | | $1,351.96 | $1,590.54 | $2,590.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,862.93
| Professional | | $1,590.54 | $1,590.54 | $1,862.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,083.61
| Professional | | $1,590.54 | $1,590.54 | $2,083.61 |