- 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
- $250.00 / $318.75 / $318.75
| Professional | | $250.00 | $318.75 | $318.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.74 / $933.74 / $933.74
| Facility | | $933.74 | $933.74 | $933.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $772.33 / $772.33 / $1,164.08
| Professional | | $772.33 | $772.33 | $1,164.08 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $100.00
| Professional | | $30.00 | $30.00 | $100.00 |