- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $509.29 / $611.15 / $611.15
| Facility | | $509.29 | $611.15 | $611.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.57 / $305.57 / $305.57
| Professional | | $305.57 | $305.57 | $305.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $550.03 / $2,291.80 / $11,000.62
| Facility | | $550.03 | $2,291.80 | $11,000.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.92 / $550.03 / $119,998.80
| Professional | | $488.92 | $550.03 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.04 / $488.92 / $1,222.19
| Facility | | $331.04 | $488.92 | $1,222.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,963.81 / $1,963.81 / $1,963.81
| Professional | | $1,963.81 | $1,963.81 | $1,963.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.12 / $203.72 / $590.77
| Professional | | $171.12 | $203.72 | $590.77 |