- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,390.25 / $1,390.25 / $1,675.00
| Facility | | $1,390.25 | $1,390.25 | $1,675.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,356.75 / $1,390.25 / $1,423.75
| Professional | | $1,356.75 | $1,390.25 | $1,423.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.84 / $65.70 / $73.00
| Professional | | $55.84 | $65.70 | $73.00 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $1,591.25 / $1,675.00 / $1,675.00
| Professional | | $1,591.25 | $1,675.00 | $1,675.00 |