- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.00 / $38.00 / $4,472.00
| Professional | | $35.00 | $38.00 | $4,472.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,872.00 / $1,872.00 / $1,872.00
| Professional | | $1,872.00 | $1,872.00 | $1,872.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,771.50 / $2,250.00
| Professional | | $1,350.00 | $1,771.50 | $2,250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.00 / $1,820.00 / $2,145.52
| Professional | | $1,573.00 | $1,820.00 | $2,145.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.00 / $60.00 / $92.65
| Professional | | $52.00 | $60.00 | $92.65 |