- 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
- $933.74 / $933.74 / $933.74
| Facility | | $933.74 | $933.74 | $933.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.08 / $1,164.08 / $1,164.08
| Professional | | $1,164.08 | $1,164.08 | $1,164.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $600.00
| Facility | | $318.75 | $318.75 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.72 / $1,432.72 / $1,432.72
| Professional | | $1,432.72 | $1,432.72 | $1,432.72 |