- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $262.50 / $300.00
| Facility | | $40.00 | $262.50 | $300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $260.00
| Professional | | $40.00 | $40.00 | $260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.00 / $259.10 / $303.20
| Professional | | $195.00 | $259.10 | $303.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $42.00
| Facility | | $40.00 | $40.00 | $42.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $52.00 / $1,126.40
| Professional | | $47.00 | $52.00 | $1,126.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $50.00 / $63.00
| Professional | | $47.00 | $50.00 | $63.00 |