- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $935.49 / $1,122.58 / $1,122.58
| Facility | | $935.49 | $1,122.58 | $1,122.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.29 / $636.13 / $636.13
| Professional | | $561.29 | $636.13 | $636.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,010.33 / $4,209.70 / $20,206.54
| Facility | | $1,010.33 | $4,209.70 | $20,206.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.07 / $1,010.33 / $119,998.80
| Professional | | $898.07 | $1,010.33 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $608.05 / $898.07 / $2,244.96
| Facility | | $608.05 | $898.07 | $2,244.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,607.24 / $3,607.24 / $3,607.24
| Professional | | $3,607.24 | $3,607.24 | $3,607.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.32 / $374.20 / $1,085.17
| Professional | | $314.32 | $374.20 | $1,085.17 |