- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.01 / $1,630.46 / $1,764.30
| Professional | | $1,482.01 | $1,630.46 | $1,764.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,350.00 / $1,377.00
| Facility | | $1,350.00 | $1,350.00 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.50 / $1,147.50 / $1,377.00
| Professional | | $1,147.50 | $1,147.50 | $1,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,784.95 / $1,784.95 / $1,784.95
| Professional | | $1,784.95 | $1,784.95 | $1,784.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.04 / $1,363.50 / $2,013.82
| Professional | | $889.04 | $1,363.50 | $2,013.82 |