- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $653.16 / $653.16 / $685.66
| Facility | | $653.16 | $653.16 | $685.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $653.16 / $653.16 / $714.30
| Professional | | $653.16 | $653.16 | $714.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,764.00 / $2,898.00 / $2,898.00
| Professional | | $1,764.00 | $2,898.00 | $2,898.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.31 / $1,342.10 / $2,950.77
| Professional | | $903.31 | $1,342.10 | $2,950.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.50 / $1,195.99 / $2,229.50
| Professional | | $585.50 | $1,195.99 | $2,229.50 |