- 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 / $418.35
| Professional | | $318.75 | $400.00 | $418.35 |
- 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
- $1,178.40 / $1,178.40 / $1,178.40
| Professional | | $1,178.40 | $1,178.40 | $1,178.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,614.76 / $1,614.76 / $1,614.76
| Facility | | $1,614.76 | $1,614.76 | $1,614.76 |