- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $785.65 / $1,046.84 / $2,100.00
| Professional | | $785.65 | $1,046.84 | $2,100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $296.37 / $1,125.51 / $1,782.96
| Facility | | $296.37 | $1,125.51 | $1,782.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.17 / $410.42 / $1,987.99
| Professional | | $282.17 | $410.42 | $1,987.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.87 / $285.61 / $459.95
| Facility | | $31.87 | $285.61 | $459.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $868.49 / $955.34 / $1,268.00
| Facility | | $868.49 | $955.34 | $1,268.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.00 / $380.00 / $380.00
| Professional | | $380.00 | $380.00 | $380.00 |