- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $1,050.00 / $1,110.00
| Facility | | $30.00 | $1,050.00 | $1,110.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $800.00
| Professional | | $30.00 | $30.00 | $800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.00 / $720.27 / $898.83
| Professional | | $414.00 | $720.27 | $898.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $704.10 / $704.10 / $760.00
| Professional | | $704.10 | $704.10 | $760.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.00 / $71.54 / $111.59
| Professional | | $46.00 | $71.54 | $111.59 |