- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.04 / $585.04 / $1,771.57
| Professional | | $585.04 | $585.04 | $1,771.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $576.00 / $2,261.52 / $3,768.48
| Facility | | $576.00 | $2,261.52 | $3,768.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.40 / $576.00 / $669.60
| Professional | | $482.40 | $576.00 | $669.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.40 / $569.40 / $734.23
| Professional | | $569.40 | $569.40 | $734.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.04 / $1,771.57 / $2,533.35
| Facility | | $585.04 | $1,771.57 | $2,533.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.62 / $1,385.62 / $1,385.62
| Professional | | $1,385.62 | $1,385.62 | $1,385.62 |