- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $570.00 / $570.00 / $4,651.20
| Facility | | $570.00 | $570.00 | $4,651.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $570.00 / $570.00 / $570.00
| Professional | | $570.00 | $570.00 | $570.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.00 / $608.00 / $608.00
| Professional | | $608.00 | $608.00 | $608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,235.00 / $1,284.40 / $2,762.83
| Facility | | $1,235.00 | $1,284.40 | $2,762.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.50 / $873.50 / $1,091.86
| Professional | | $873.50 | $873.50 | $1,091.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,544.85 / $1,544.85 / $1,544.85
| Professional | | $1,544.85 | $1,544.85 | $1,544.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.00 / $912.00 / $912.00
| Facility | | $912.00 | $912.00 | $912.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.20 / $342.00 / $691.58
| Professional | | $319.20 | $342.00 | $691.58 |