- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.75 / $806.74 / $998.44
| Professional | | $798.75 | $806.74 | $998.44 |
- 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
- $1,155.93 / $1,155.93 / $2,486.42
| Professional | | $1,155.93 | $1,155.93 | $2,486.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.93 / $1,155.93 / $1,155.93
| Professional | | $1,155.93 | $1,155.93 | $1,155.93 |