- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $588.84 / $1,000.00
| Facility | | $354.81 | $588.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $489.78
| Professional | | $354.81 | $354.81 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $467.74 / $977.24
| Facility | | $363.08 | $467.74 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $478.63
| Professional | | $354.81 | $354.81 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $354.81 / $512.86
| Facility | | $331.13 | $354.81 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $363.08 / $457.09
| Professional | | $354.81 | $363.08 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $354.81 / $616.60
| Facility | | $288.40 | $354.81 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $354.81 / $416.87
| Professional | | $346.74 | $354.81 | $416.87 |