- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $870.96 / $1,047.13
| Professional | | $575.44 | $870.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $1,698.24
| Professional | | $741.31 | $1,071.52 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Facility | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Professional | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $870.96 / $1,148.15
| Professional | | $645.65 | $870.96 | $1,148.15 |