- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $42.42 / $1,006.56
| Professional | | $30.00 | $42.42 | $1,006.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.48 / $648.48 / $1,438.40
| Professional | | $648.48 | $648.48 | $1,438.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.00 / $975.00 / $1,680.00
| Professional | | $600.00 | $975.00 | $1,680.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.42 / $960.00 / $1,096.32
| Professional | | $42.42 | $960.00 | $1,096.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $60.00 / $75.00
| Professional | | $50.00 | $60.00 | $75.00 |