- 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
- $101.23 / $101.23 / $101.23
| Facility | | $101.23 | $101.23 | $101.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.00 / $25.00 / $42.50
| Facility | | $25.00 | $25.00 | $42.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.00 / $25.00 / $25.00
| Professional | | $25.00 | $25.00 | $25.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.11 / $68.11 / $84.07
| Professional | | $68.11 | $68.11 | $84.07 |