- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.50 / $1,377.00 / $1,377.00
| Professional | | $1,300.50 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Facility | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,377.00 / $1,377.00 / $1,377.00
| Professional | | $1,377.00 | $1,377.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,490.67 / $1,852.86 / $2,236.01
| Professional | | $1,490.67 | $1,852.86 | $2,236.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,480.06
| Professional | | $1,350.00 | $1,350.00 | $1,480.06 |