- 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
- $150.00 / $417.50 / $530.15
| Professional | | $150.00 | $417.50 | $530.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.00 / $60.00 / $94.50
| Professional | | $36.00 | $60.00 | $94.50 |