- 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
- $1,040.19 / $1,040.19 / $1,040.19
| Facility | | $1,040.19 | $1,040.19 | $1,040.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,211.13 / $1,211.13 / $1,211.13
| Professional | | $1,211.13 | $1,211.13 | $1,211.13 |
- 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
- $1,490.62 / $1,490.62 / $1,490.62
| Professional | | $1,490.62 | $1,490.62 | $1,490.62 |