- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.75 / $663.85 / $852.00
| Facility | | $585.75 | $663.85 | $852.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.30 / $376.30 / $376.30
| Professional | | $376.30 | $376.30 | $376.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.11 / $802.30 / $887.50
| Professional | | $669.11 | $802.30 | $887.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $781.00 / $852.00 / $994.00
| Professional | | $781.00 | $852.00 | $994.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.00 / $852.00 / $1,065.00
| Professional | | $710.00 | $852.00 | $1,065.00 |