- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $703.37 / $703.37 / $703.37
| Facility | | $703.37 | $703.37 | $703.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.32 / $703.37 / $1,094.58
| Professional | | $675.32 | $703.37 | $1,094.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.69 / $914.10 / $1,508.26
| Professional | | $822.69 | $914.10 | $1,508.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.54 / $2,192.67 / $3,455.95
| Professional | | $855.54 | $2,192.67 | $3,455.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.24 / $1,752.25 / $1,752.25
| Professional | | $808.24 | $1,752.25 | $1,752.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.67 / $1,007.20 / $2,217.08
| Professional | | $586.67 | $1,007.20 | $2,217.08 |