- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.55 / $1,291.55 / $2,224.00
| Professional | | $1,291.55 | $1,291.55 | $2,224.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,480.34 / $2,480.34 / $2,480.34
| Professional | | $2,480.34 | $2,480.34 | $2,480.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $2,793.86
| Facility | | $1,460.50 | $1,460.50 | $2,793.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,460.50
| Professional | | $1,460.50 | $1,460.50 | $1,460.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.36 / $1,095.38 / $1,650.02
| Professional | | $928.36 | $1,095.38 | $1,650.02 |