- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.58 / $875.58 / $1,010.28
| Professional | | $875.58 | $875.58 | $1,010.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.50 / $870.50 / $1,318.76
| Facility | | $870.50 | $870.50 | $1,318.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.47 / $870.50 / $896.62
| Professional | | $635.47 | $870.50 | $896.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.50 / $870.50 / $1,318.76
| Facility | | $870.50 | $870.50 | $1,318.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $635.47 / $870.50 / $896.62
| Professional | | $635.47 | $870.50 | $896.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $596.75 / $1,062.85 / $2,074.23
| Professional | | $596.75 | $1,062.85 | $2,074.23 |