- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $868.78 / $868.78 / $1,085.98
| Professional | | $868.78 | $868.78 | $1,085.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $844.83 / $844.83 / $1,683.81
| Facility | | $844.83 | $844.83 | $1,683.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.00 / $5,247.00 / $5,247.00
| Professional | | $922.00 | $5,247.00 | $5,247.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.00 / $1,002.00 / $1,002.00
| Facility | | $1,002.00 | $1,002.00 | $1,002.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.34 / $798.74 / $1,100.00
| Professional | | $751.34 | $798.74 | $1,100.00 |