- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.38 / $863.93 / $1,069.22
| Professional | | $855.38 | $863.93 | $1,069.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $90.00
| Facility | | $90.00 | $90.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.42 / $1,328.42 / $2,849.18
| Professional | | $1,328.42 | $1,328.42 | $2,849.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.42 / $1,328.42 / $1,328.42
| Professional | | $1,328.42 | $1,328.42 | $1,328.42 |