- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,653.82 / $1,733.69
| Facility | | $1,590.54 | $1,653.82 | $1,733.69 |
- 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
- 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
- $194.89 / $1,725.59 / $3,000.00
| Professional | | $194.89 | $1,725.59 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.38 / $127.38 / $127.38
| Professional | | $127.38 | $127.38 | $127.38 |
- 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 |