- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Facility | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.00 / $50.00 / $529.27
| Professional | | $35.00 | $50.00 | $529.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.58 / $420.00 / $1,500.00
| Professional | | $110.58 | $420.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.00 / $543.90 / $586.25
| Professional | | $490.00 | $543.90 | $586.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $59.00 / $90.00
| Professional | | $47.00 | $59.00 | $90.00 |