- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.60 / $627.36 / $10,608.00
| Professional | | $612.60 | $627.36 | $10,608.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,195.28 / $1,195.28 / $1,389.68
| Facility | | $1,195.28 | $1,195.28 | $1,389.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,384.02 / $1,384.02 / $1,384.02
| Facility | | $1,384.02 | $1,384.02 | $1,384.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.36 / $627.36 / $627.36
| Professional | | $627.36 | $627.36 | $627.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,384.02 / $1,384.02 / $1,384.02
| Facility | | $1,384.02 | $1,384.02 | $1,384.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.36 / $627.36 / $627.36
| Professional | | $627.36 | $627.36 | $627.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.05 / $627.36 / $1,845.18
| Professional | | $615.05 | $627.36 | $1,845.18 |