- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.50 / $713.50 / $713.50
| Professional | | $713.50 | $713.50 | $713.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $673.11 / $1,104.07 / $1,840.12
| Facility | | $673.11 | $1,104.07 | $1,840.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.50 / $713.50 / $1,840.12
| Professional | | $713.50 | $713.50 | $1,840.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $673.11 / $1,104.07 / $1,840.12
| Facility | | $673.11 | $1,104.07 | $1,840.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.50 / $713.50 / $1,840.12
| Professional | | $713.50 | $713.50 | $1,840.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.50 / $713.50 / $2,140.50
| Professional | | $713.50 | $713.50 | $2,140.50 |