- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,670.07 / $1,670.07
| Facility | | $1,590.54 | $1,670.07 | $1,670.07 |
- 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
- $1,590.54 / $1,590.54 / $2,123.05
| Professional | | $1,590.54 | $1,590.54 | $2,123.05 |
- 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
- $1,500.51 / $1,500.51 / $1,590.54
| Facility | | $1,500.51 | $1,500.51 | $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
- $1,351.96 / $1,590.54 / $2,590.69
| Professional | | $1,351.96 | $1,590.54 | $2,590.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $2,544.86
| Facility | | $1,590.54 | $1,590.54 | $2,544.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.54 / $224.00 / $331.90
| Professional | | $175.54 | $224.00 | $331.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,590.54 / $1,590.54 / $1,996.13
| Professional | | $1,590.54 | $1,590.54 | $1,996.13 |