- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $45.00 / $1,430.00 / $1,950.00
| Facility | | $45.00 | $1,430.00 | $1,950.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.00 / $43.26 / $1,965.86
| Professional | | $35.00 | $43.26 | $1,965.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.00 / $1,352.00 / $2,106.00
| Professional | | $1,001.00 | $1,352.00 | $2,106.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.50 / $1,750.00 / $2,372.50
| Professional | | $1,187.50 | $1,750.00 | $2,372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $59.00 / $86.00
| Professional | | $45.00 | $59.00 | $86.00 |