- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.00 / $275.00 / $275.00
| Facility | | $275.00 | $275.00 | $275.00 |
- 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
- $308.00 / $340.00 / $388.00
| Professional | | $308.00 | $340.00 | $388.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $87.00 / $100.00
| Professional | | $55.00 | $87.00 | $100.00 |