- 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
- $975.64 / $975.64 / $975.64
| Facility | | $975.64 | $975.64 | $975.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,338.15 / $1,338.15 / $1,338.15
| Professional | | $1,338.15 | $1,338.15 | $1,338.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $397.28 / $616.00
| Facility | | $318.75 | $397.28 | $616.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,438.18 / $1,438.18 / $1,438.18
| Professional | | $1,438.18 | $1,438.18 | $1,438.18 |