- 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 / $457.09
| Professional | | $354.81 | $354.81 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $489.78 / $1,000.00
| Facility | | $380.19 | $489.78 | $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
- $338.84 / $354.81 / $512.86
| Facility | | $338.84 | $354.81 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $407.38
| Professional | | $354.81 | $354.81 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $354.81 / $602.56
| Facility | | $338.84 | $354.81 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $354.81 / $407.38
| Professional | | $338.84 | $354.81 | $407.38 |