- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $570.00 / $836.00 / $4,113.50
| Facility | | $570.00 | $836.00 | $4,113.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.00 / $665.00 / $855.00
| Professional | | $570.00 | $665.00 | $855.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $521.33 / $729.85 / $3,571.48
| Facility | | $521.33 | $729.85 | $3,571.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $555.75 / $1,157.05 / $1,386.28
| Professional | | $555.75 | $1,157.05 | $1,386.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.00 / $570.00 / $830.38
| Professional | | $570.00 | $570.00 | $830.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.50 / $399.00 / $1,488.52
| Professional | | $332.50 | $399.00 | $1,488.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.00 / $570.00 / $570.00
| Professional | | $570.00 | $570.00 | $570.00 |