- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,654.16 / $1,654.16
| Professional | | $1,590.54 | $1,654.16 | $1,654.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,653.82
| Professional | | $1,590.54 | $1,590.54 | $1,653.82 |
- 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
- $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 / $1,654.16 / $1,654.16
| Professional | | $1,590.54 | $1,654.16 | $1,654.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,306.28
| Professional | | $1,590.54 | $1,590.54 | $2,306.28 |