- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.00 / $300.00 / $300.00
| Facility | | $300.00 | $300.00 | $300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.74 / $300.00 / $300.00
| Professional | | $299.74 | $300.00 | $300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.00 / $444.00 / $444.00
| Professional | | $444.00 | $444.00 | $444.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.00 / $444.00 / $444.00
| Professional | | $444.00 | $444.00 | $444.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.00 / $444.00 / $444.00
| Professional | | $125.00 | $444.00 | $444.00 |