- 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
- $1,509.07 / $1,509.07 / $1,509.07
| Facility | | $1,509.07 | $1,509.07 | $1,509.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.35 / $344.35 / $344.35
| Professional | | $344.35 | $344.35 | $344.35 |
- 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
- $1,845.78 / $1,845.78 / $1,845.78
| Professional | | $1,845.78 | $1,845.78 | $1,845.78 |