- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.00 / $1,746.00 / $2,995.40
| Professional | | $1,746.00 | $1,746.00 | $2,995.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,340.70 / $3,340.70 / $3,340.70
| Professional | | $3,340.70 | $3,340.70 | $3,340.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.00 / $2,160.00 / $2,875.95
| Facility | | $2,160.00 | $2,160.00 | $2,875.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.00 / $2,160.00 / $2,160.00
| Professional | | $2,160.00 | $2,160.00 | $2,160.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.36 / $1,469.64 / $2,577.27
| Professional | | $1,077.36 | $1,469.64 | $2,577.27 |