- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,430.00 / $1,430.00 / $1,430.00
| Facility | | $1,430.00 | $1,430.00 | $1,430.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $56.00
| Professional | | $45.00 | $45.00 | $56.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.00 / $80.00 / $80.00
| Professional | | $80.00 | $80.00 | $80.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.00 / $2,125.00 / $2,425.00
| Professional | | $1,925.00 | $2,125.00 | $2,425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $88.00 / $105.00
| Professional | | $55.00 | $88.00 | $105.00 |