- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $48.00 / $408.00
| Facility | | $40.00 | $48.00 | $408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.81 / $45.00 / $61.00
| Professional | | $33.81 | $45.00 | $61.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.50 / $285.00 / $400.00
| Professional | | $237.50 | $285.00 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.00 / $310.00 / $310.00
| Professional | | $310.00 | $310.00 | $310.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $50.00 / $58.00
| Professional | | $40.00 | $50.00 | $58.00 |