- 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 / $1,805.02
| Professional | | $1,640.93 | $1,640.93 | $1,805.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,579.05 / $1,857.70 / $1,857.70
| Facility | | $1,579.05 | $1,857.70 | $1,857.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.81 / $1,857.70 / $1,857.70
| Professional | | $1,764.81 | $1,857.70 | $1,857.70 |
- 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
- $386.58 / $1,537.56 / $2,059.16
| Professional | | $386.58 | $1,537.56 | $2,059.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,476.84 / $2,707.53 / $3,117.77
| Facility | | $1,476.84 | $2,707.53 | $3,117.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.14 / $1,640.93 / $1,640.93
| Professional | | $322.14 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $386.58 / $496.11 / $1,969.11
| Facility | | $386.58 | $496.11 | $1,969.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.58 / $1,537.56 / $2,059.16
| Professional | | $386.58 | $1,537.56 | $2,059.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,558.88 / $1,640.93 / $1,640.93
| Professional | | $1,558.88 | $1,640.93 | $1,640.93 |