- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $608.66 / $927.84 / $1,113.41
| Facility | | $608.66 | $927.84 | $1,113.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.70 / $608.66 / $630.92
| Professional | | $556.70 | $608.66 | $630.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,002.06 / $4,175.27 / $20,041.30
| Facility | | $1,002.06 | $4,175.27 | $20,041.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.72 / $1,002.06 / $119,998.80
| Professional | | $890.72 | $1,002.06 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $603.10 / $890.72 / $2,226.65
| Facility | | $603.10 | $890.72 | $2,226.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,577.74 / $3,577.74 / $3,577.74
| Professional | | $3,577.74 | $3,577.74 | $3,577.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.75 / $371.14 / $1,076.29
| Professional | | $311.75 | $371.14 | $1,076.29 |