- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $2,730.00 / $2,886.00
| Facility | | $30.00 | $2,730.00 | $2,886.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $2,080.00
| Professional | | $30.00 | $30.00 | $2,080.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.00 / $2,000.75 / $2,496.75
| Professional | | $1,150.00 | $2,000.75 | $2,496.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,830.66 / $1,830.66 / $1,976.00
| Professional | | $1,830.66 | $1,830.66 | $1,976.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.00 / $71.54 / $111.59
| Professional | | $46.00 | $71.54 | $111.59 |