- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $400.00 / $400.00 / $400.00
| Facility | | $400.00 | $400.00 | $400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.57 / $125.82 / $755.47
| Professional | | $87.57 | $125.82 | $755.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $486.00 / $486.00 / $486.00
| Professional | | $486.00 | $486.00 | $486.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $45.00 / $60.00
| Professional | | $30.00 | $45.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.72 / $44.13 / $57.51
| Professional | | $39.72 | $44.13 | $57.51 |