- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.37 / $848.37 / $1,326.54
| Professional | | $848.37 | $848.37 | $1,326.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.44 / $1,479.44 / $1,479.44
| Facility | | $1,479.44 | $1,479.44 | $1,479.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.44 / $1,479.44 / $1,479.44
| Professional | | $1,479.44 | $1,479.44 | $1,479.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $842.96 / $842.96 / $1,483.96
| Facility | | $842.96 | $842.96 | $1,483.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.36 / $615.36 / $842.96
| Professional | | $615.36 | $615.36 | $842.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.29 / $673.03 / $747.19
| Professional | | $608.29 | $673.03 | $747.19 |