- 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
- $1,047.49 / $1,047.49 / $1,047.49
| Facility | | $1,047.49 | $1,047.49 | $1,047.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,079.31 / $1,079.31 / $1,079.31
| Professional | | $1,079.31 | $1,079.31 | $1,079.31 |
- 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
- $1,328.38 / $1,328.38 / $1,328.38
| Professional | | $1,328.38 | $1,328.38 | $1,328.38 |