- 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
- $1,360.46 / $1,360.46 / $1,360.46
| Facility | | $1,360.46 | $1,360.46 | $1,360.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.40 / $1,178.40 / $1,178.40
| Professional | | $1,178.40 | $1,178.40 | $1,178.40 |
- 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
- $1,450.34 / $1,450.34 / $1,450.34
| Professional | | $1,450.34 | $1,450.34 | $1,450.34 |