- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,122.02 / $1,202.26
| Facility | | $954.99 | $1,122.02 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $47.86 / $1,548.82
| Professional | | $30.20 | $47.86 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $977.24 / $1,548.82
| Professional | | $616.60 | $977.24 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,762.47 / $7,762.47
| Professional | | $3,630.78 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $54.95 / $85.11
| Professional | | $39.81 | $54.95 | $85.11 |