- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $48.00 / $1,768.00
| Facility | | $40.00 | $48.00 | $1,768.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.81 / $42.00 / $61.00
| Professional | | $33.81 | $42.00 | $61.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.50 / $1,425.00 / $2,000.00
| Professional | | $1,187.50 | $1,425.00 | $2,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,550.00 / $1,550.00 / $1,550.00
| Professional | | $1,550.00 | $1,550.00 | $1,550.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $58.00
| Professional | | $40.00 | $50.00 | $58.00 |