- 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
- $32.50 / $43.26 / $50.00
| Professional | | $32.50 | $43.26 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.00 / $48.00 / $85.98
| Professional | | $48.00 | $48.00 | $85.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.00 / $2,087.50 / $2,650.75
| Professional | | $750.00 | $2,087.50 | $2,650.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.00 / $65.00 / $94.50
| Professional | | $36.00 | $65.00 | $94.50 |