- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.00 / $330.00 / $330.00
| Facility | | $330.00 | $330.00 | $330.00 |
- 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
- $400.00 / $400.00 / $400.00
| Professional | | $400.00 | $400.00 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.00 / $425.00 / $485.00
| Professional | | $400.00 | $425.00 | $485.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $87.00 / $100.00
| Professional | | $55.00 | $87.00 | $100.00 |