- 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 / $1,706.57
| Professional | | $1,640.93 | $1,640.93 | $1,706.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.93 / $2,182.75 / $5,436.40
| Facility | | $1,640.93 | $2,182.75 | $5,436.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $5,460.00
| Professional | | $1,640.93 | $1,640.93 | $5,460.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.04 / $50.71 / $64.69
| Facility | | $44.04 | $50.71 | $64.69 |
- 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
- $1,640.93 / $2,461.40 / $8,090.00
| Facility | | $1,640.93 | $2,461.40 | $8,090.00 |
- 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
- 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
- $2,182.75 / $2,182.75 / $2,631.69
| Facility | | $2,182.75 | $2,182.75 | $2,631.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $5,460.00
| Professional | | $1,640.93 | $1,640.93 | $5,460.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.27 / $1,640.93 / $2,461.40
| Professional | | $1,389.27 | $1,640.93 | $2,461.40 |