- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $318.75
| Facility | | $318.75 | $318.75 | $318.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $475.00
| Professional | | $318.75 | $318.75 | $475.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,049.91 / $1,049.91 / $1,049.91
| Facility | | $1,049.91 | $1,049.91 | $1,049.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,035.86 / $1,035.86 / $1,035.86
| Professional | | $1,035.86 | $1,035.86 | $1,035.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $414.38 / $616.00
| Facility | | $318.75 | $414.38 | $616.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.91 / $1,274.91 / $1,274.91
| Professional | | $1,274.91 | $1,274.91 | $1,274.91 |