- 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 / $378.05
| Professional | | $35.00 | $50.00 | $378.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.72 / $280.00 / $1,500.00
| Professional | | $73.72 | $280.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $388.50 / $418.75
| Professional | | $350.00 | $388.50 | $418.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $60.00 / $90.00
| Professional | | $47.00 | $60.00 | $90.00 |