- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.47 / $877.47 / $1,012.47
| Professional | | $877.47 | $877.47 | $1,012.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.78 / $1,191.78 / $1,191.78
| Facility | | $1,191.78 | $1,191.78 | $1,191.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.00 / $870.00 / $1,227.53
| Professional | | $870.00 | $870.00 | $1,227.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,191.78 / $1,191.78 / $1,191.78
| Facility | | $1,191.78 | $1,191.78 | $1,191.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.00 / $1,191.78 / $1,227.53
| Professional | | $870.00 | $1,191.78 | $1,227.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.04 / $1,065.16 / $2,078.73
| Professional | | $598.04 | $1,065.16 | $2,078.73 |