- 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
- Facility
- Modifier
- Low / Median / High Price
- $148.91 / $192.72 / $1,590.54
| Facility | | $148.91 | $192.72 | $1,590.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,800.61
| Professional | | $1,590.54 | $1,590.54 | $1,800.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,575.54 / $1,590.54 / $2,625.89
| Professional | | $1,575.54 | $1,590.54 | $2,625.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,853.66 / $13,785.00 / $13,785.00
| Facility | | $1,853.66 | $13,785.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.82 / $1,853.66 / $1,853.66
| Professional | | $134.82 | $1,853.66 | $1,853.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,908.65
| Professional | | $1,590.54 | $1,590.54 | $1,908.65 |