- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $446.68 / $537.03
| Professional | | $323.59 | $446.68 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $660.69
| Facility | | $549.54 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $691.83
| Professional | | $562.34 | $562.34 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $724.44 / $1,000.00
| Professional | | $588.84 | $724.44 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $489.78 / $588.84
| Facility | | $407.38 | $489.78 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $562.34 / $1,584.89
| Professional | | $263.03 | $562.34 | $1,584.89 |