- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.81 / $57.54 / $1,778.28
| Facility | | $39.81 | $57.54 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $44.67 / $1,949.84
| Professional | | $34.67 | $44.67 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $1,995.26
| Professional | | $1,174.90 | $1,412.54 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $50.12 / $60.26
| Professional | | $39.81 | $50.12 | $60.26 |