- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,653.82
| Facility | | $1,590.54 | $1,590.54 | $1,653.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,749.59
| Professional | | $1,590.54 | $1,590.54 | $1,749.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,530.55 / $1,800.65 / $1,800.65
| Facility | | $1,530.55 | $1,800.65 | $1,800.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,710.61 / $1,800.65 / $1,872.28
| Professional | | $1,710.61 | $1,800.65 | $1,872.28 |
- 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
- $159.24 / $1,590.54 / $2,854.63
| Professional | | $159.24 | $1,590.54 | $2,854.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.77 / $2,224.39 / $3,142.26
| Facility | | $309.77 | $2,224.39 | $3,142.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.82 / $1,653.82 / $2,878.56
| Professional | | $1,653.82 | $1,653.82 | $2,878.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.24 / $2,224.39 / $2,854.63
| Facility | | $159.24 | $2,224.39 | $2,854.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.24 / $1,984.58 / $2,854.63
| Professional | | $159.24 | $1,984.58 | $2,854.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,511.01 / $1,590.54 / $1,853.66
| Professional | | $1,511.01 | $1,590.54 | $1,853.66 |