- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.28 / $231.28 / $462.56
| Facility | | $231.28 | $231.28 | $462.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.26 / $241.67 / $276.30
| Professional | | $184.26 | $241.67 | $276.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $534.87 / $3,565.80 / $7,488.18
| Facility | | $534.87 | $3,565.80 | $7,488.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.22 / $119,998.80 / $119,998.80
| Professional | | $230.22 | $119,998.80 | $119,998.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $287.45 / $287.45 / $287.45
| Facility | | $287.45 | $287.45 | $287.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.06 / $1,202.06 / $1,202.06
| Professional | | $1,202.06 | $1,202.06 | $1,202.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.20 / $301.88 / $509.14
| Professional | | $193.20 | $301.88 | $509.14 |