- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $735.24 / $833.27 / $980.32
| Facility | | $735.24 | $833.27 | $980.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.15 / $950.92 / $1,157.42
| Professional | | $34.15 | $950.92 | $1,157.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.00 / $28.00 / $28.00
| Professional | | $28.00 | $28.00 | $28.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.57 / $1,077.57 / $1,077.57
| Professional | | $1,077.57 | $1,077.57 | $1,077.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.10 / $1,054.60 / $1,442.66
| Professional | | $888.10 | $1,054.60 | $1,442.66 |