- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $507.50 / $507.50 / $1,305.00
| Facility | | $507.50 | $507.50 | $1,305.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.50 / $507.50 / $681.50
| Professional | | $507.50 | $507.50 | $681.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.31 / $1,460.88 / $1,631.25
| Professional | | $1,091.31 | $1,460.88 | $1,631.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.02 / $833.02 / $1,222.91
| Professional | | $833.02 | $833.02 | $1,222.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $435.00 / $551.00 / $1,305.00
| Facility | | $435.00 | $551.00 | $1,305.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.75 / $870.00 / $1,450.00
| Professional | | $369.75 | $870.00 | $1,450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.50 / $739.50 / $1,232.50
| Professional | | $304.50 | $739.50 | $1,232.50 |