- 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 / $453.66
| Professional | | $35.00 | $50.00 | $453.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.15 / $350.00 / $1,500.00
| Professional | | $92.15 | $350.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.00 / $466.20 / $502.50
| Professional | | $420.00 | $466.20 | $502.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $60.00 / $84.00
| Professional | | $47.00 | $60.00 | $84.00 |