- 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
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.77 / $1,098.77 / $1,098.77
| Professional | | $1,098.77 | $1,098.77 | $1,098.77 |
- 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
- $1,352.33 / $1,352.33 / $1,352.33
| Professional | | $1,352.33 | $1,352.33 | $1,352.33 |