- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.75 / $1,356.75 / $1,390.25
| Professional | | $1,356.75 | $1,356.75 | $1,390.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.10 / $1,380.10 / $1,380.10
| Facility | | $1,380.10 | $1,380.10 | $1,380.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.10 / $1,380.10 / $1,380.10
| Professional | | $1,380.10 | $1,380.10 | $1,380.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.50 / $1,940.15 / $8,883.66
| Facility | | $1,373.50 | $1,940.15 | $8,883.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.00 / $1,675.00 / $3,634.75
| Professional | | $1,675.00 | $1,675.00 | $3,634.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.00 / $1,675.00 / $1,675.00
| Professional | | $1,675.00 | $1,675.00 | $1,675.00 |