- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $608.17 / $729.81 / $729.81
| Facility | | $608.17 | $729.81 | $729.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.91 / $389.23 / $413.56
| Professional | | $364.91 | $389.23 | $413.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $656.83 / $2,736.79 / $13,136.58
| Facility | | $656.83 | $2,736.79 | $13,136.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.85 / $656.83 / $119,998.80
| Professional | | $583.85 | $656.83 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $395.31 / $583.85 / $1,459.49
| Facility | | $395.31 | $583.85 | $1,459.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,345.12 / $2,345.12 / $2,345.12
| Professional | | $2,345.12 | $2,345.12 | $2,345.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.92 / $291.92 / $291.92
| Facility | | $291.92 | $291.92 | $291.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.35 / $243.27 / $705.48
| Professional | | $204.35 | $243.27 | $705.48 |