- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $25.00 / $25.00
| Professional | | $25.00 | $25.00 | $25.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.67 / $101.20 / $126.50
| Facility | | $98.67 | $101.20 | $126.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.90 / $101.20 / $168.25
| Professional | | $75.90 | $101.20 | $168.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.00 / $25.00 / $27.50
| Facility | | $25.00 | $25.00 | $27.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $25.00 / $25.00
| Professional | | $25.00 | $25.00 | $25.00 |