- 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
- $450.00 / $1,252.50 / $1,590.45
| Professional | | $450.00 | $1,252.50 | $1,590.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.00 / $55.55 / $92.00
| Professional | | $36.00 | $55.55 | $92.00 |