- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $1,000.00 / $1,318.26
| Facility | | $562.34 | $1,000.00 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $676.08
| Professional | | $562.34 | $562.34 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $562.34 / $575.44
| Facility | | $524.81 | $562.34 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $602.56
| Professional | | $562.34 | $562.34 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $562.34 / $977.24
| Facility | | $537.03 | $562.34 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $562.34 / $575.44
| Professional | | $537.03 | $562.34 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | | $562.34 | $562.34 | $562.34 |