- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $1,000.00
| Facility | | $562.34 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $776.25
| Professional | | $562.34 | $562.34 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $616.60
| Facility | | $602.56 | $602.56 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $602.56 / $616.60
| Professional | | $457.09 | $602.56 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $660.69
| Facility | | $575.44 | $575.44 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $707.95
| Professional | | $562.34 | $562.34 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $954.99
| Facility | | $537.03 | $537.03 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $562.34 / $602.56
| Professional | | $537.03 | $562.34 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $562.34 / $630.96
| Professional | | $478.63 | $562.34 | $630.96 |