- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $1,680.00 / $1,776.00
| Facility | | $30.00 | $1,680.00 | $1,776.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $1,280.00
| Professional | | $30.00 | $30.00 | $1,280.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.00 / $1,200.45 / $1,498.05
| Professional | | $690.00 | $1,200.45 | $1,498.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.56 / $1,126.56 / $1,216.00
| Professional | | $1,126.56 | $1,126.56 | $1,216.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.00 / $81.14 / $111.59
| Professional | | $46.00 | $81.14 | $111.59 |