- 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
- $207.50 / $207.50 / $207.50
| Professional | | $207.50 | $207.50 | $207.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.00 / $432.50 / $556.60
| Professional | | $265.00 | $432.50 | $556.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.00 / $380.00 / $380.00
| Professional | | $380.00 | $380.00 | $380.00 |