- 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
- $133.62 / $133.62 / $133.62
| Facility | | $133.62 | $133.62 | $133.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.64 / $889.64 / $889.64
| Professional | | $889.64 | $889.64 | $889.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $318.75 / $600.00
| Facility | | $318.75 | $318.75 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,094.94 / $1,094.94 / $1,094.94
| Professional | | $1,094.94 | $1,094.94 | $1,094.94 |