- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $42.42 / $1,635.66
| Professional | | $30.00 | $42.42 | $1,635.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.78 / $1,053.78 / $2,337.40
| Professional | | $1,053.78 | $1,053.78 | $2,337.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,625.00 / $2,800.00
| Professional | | $1,000.00 | $1,625.00 | $2,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.42 / $1,560.00 / $1,781.52
| Professional | | $42.42 | $1,560.00 | $1,781.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $60.00 / $88.76
| Professional | | $50.00 | $60.00 | $88.76 |