- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $630.00 / $666.00
| Facility | | $30.00 | $630.00 | $666.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $480.00
| Professional | | $30.00 | $30.00 | $480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.00 / $432.50 / $1,525.00
| Professional | | $265.00 | $432.50 | $1,525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.46 / $422.46 / $456.00
| Professional | | $422.46 | $422.46 | $456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $81.37 / $111.59
| Professional | | $47.00 | $81.37 | $111.59 |