- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.00 / $56.00 / $2,598.44
| Facility | | $56.00 | $56.00 | $2,598.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $56.00 / $2,598.44
| Professional | | $40.00 | $56.00 | $2,598.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.00 / $1,768.75 / $2,421.00
| Professional | | $1,300.00 | $1,768.75 | $2,421.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.25 / $1,357.46 / $1,618.51
| Professional | | $593.25 | $1,357.46 | $1,618.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,503.68 / $1,795.82 / $2,083.38
| Professional | | $1,503.68 | $1,795.82 | $2,083.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.00 / $52.00 / $76.00
| Professional | | $38.00 | $52.00 | $76.00 |