- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.36 / $901.36 / $1,126.70
| Professional | | $901.36 | $901.36 | $1,126.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $402.26 / $701.98 / $3,565.85
| Facility | | $402.26 | $701.98 | $3,565.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.00 / $1,655.89 / $1,655.89
| Professional | | $470.00 | $1,655.89 | $1,655.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $470.00 / $471.61 / $777.22
| Facility | | $470.00 | $471.61 | $777.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.61 / $499.00 / $777.22
| Professional | | $471.61 | $499.00 | $777.22 |