- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,202.26 / $2,089.30
| Professional | | $707.95 | $1,202.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,348.96 / $2,089.30
| Professional | | $891.25 | $1,348.96 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,318.26 / $2,089.30
| Professional | | $1,202.26 | $1,318.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $1,737.80
| Professional | | $1,122.02 | $1,318.26 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $3,090.30
| Professional | | $1,096.48 | $1,445.44 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $1,949.84
| Professional | | $1,096.48 | $1,513.56 | $1,949.84 |