- 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 / $1,657.34
| Professional | | $1,640.93 | $1,640.93 | $1,657.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.79 / $1,664.53 / $1,802.50
| Professional | | $1,479.79 | $1,664.53 | $1,802.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,609.08 / $2,609.08 / $3,000.44
| Facility | | $2,609.08 | $2,609.08 | $3,000.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.24 / $410.30 / $1,640.93
| Professional | | $328.24 | $410.30 | $1,640.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,640.93 / $2,051.17 / $2,953.67
| Facility | | $1,640.93 | $2,051.17 | $2,953.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.14 / $1,640.93 / $1,837.84
| Professional | | $322.14 | $1,640.93 | $1,837.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,782.13
| Professional | | $1,640.93 | $1,640.93 | $1,782.13 |