- 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 / $397.28 / $397.28
| Professional | | $318.75 | $397.28 | $397.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.00 / $1,520.00 / $1,520.00
| Facility | | $1,520.00 | $1,520.00 | $1,520.00 |
- 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
- $455.81 / $671.40 / $802.75
| Facility | | $455.81 | $671.40 | $802.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.11 / $349.11 / $1,001.61
| Facility | | $289.11 | $349.11 | $1,001.61 |