- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $750.00
| Facility | | $318.75 | $318.75 | $750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.75 / $400.00 / $425.00
| Professional | | $318.75 | $400.00 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.90 / $770.09 / $2,397.36
| Facility | | $376.90 | $770.09 | $2,397.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,366.30 / $1,471.54 / $1,471.54
| Professional | | $1,366.30 | $1,471.54 | $1,471.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.28 / $1,001.28 / $1,001.28
| Facility | | $1,001.28 | $1,001.28 | $1,001.28 |