- 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
- $1,236.33 / $1,236.33 / $1,236.33
| Facility | | $1,236.33 | $1,236.33 | $1,236.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.84 / $1,761.84 / $1,761.84
| Professional | | $1,761.84 | $1,761.84 | $1,761.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $342.08 / $600.00
| Facility | | $318.75 | $342.08 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.47 / $1,463.47 / $1,463.47
| Professional | | $1,463.47 | $1,463.47 | $1,463.47 |