- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,706.57 / $1,706.57
| Professional | | $1,640.93 | $1,706.57 | $1,706.57 |
- 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 / $1,640.93 / $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
- 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 / $1,706.57 / $1,706.57
| Professional | | $1,640.93 | $1,706.57 | $1,706.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $2,379.35
| Professional | | $1,640.93 | $1,640.93 | $2,379.35 |