- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Facility | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,690.16
| Professional | | $1,640.93 | $1,640.93 | $1,690.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Facility | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.05 / $1,548.05 / $2,069.88
| Facility | | $1,548.05 | $1,548.05 | $2,069.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,739.38 / $2,704.74
| Facility | | $1,640.93 | $1,739.38 | $2,704.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,788.61 / $1,805.02 / $2,330.12
| Professional | | $1,788.61 | $1,805.02 | $2,330.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |