- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.38 / $614.85 / $614.85
| Facility | | $512.38 | $614.85 | $614.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.43 / $307.43 / $307.43
| Professional | | $307.43 | $307.43 | $307.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $553.37 / $2,305.69 / $11,067.30
| Facility | | $553.37 | $2,305.69 | $11,067.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.88 / $553.37 / $119,998.80
| Professional | | $491.88 | $553.37 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.05 / $491.88 / $1,229.61
| Facility | | $333.05 | $491.88 | $1,229.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,975.72 / $1,975.72 / $1,975.72
| Professional | | $1,975.72 | $1,975.72 | $1,975.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.46 / $204.95 / $655.84
| Professional | | $184.46 | $204.95 | $655.84 |