- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $5.00
| Professional | | $5.00 | $5.00 | $5.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.55 / $22.55 / $22.55
| Facility | | $22.55 | $22.55 | $22.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.55 / $22.55 / $23.23
| Professional | | $22.55 | $22.55 | $23.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.00 / $22.55 / $22.55
| Facility | | $5.00 | $22.55 | $22.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.55 / $22.55 / $23.23
| Professional | | $22.55 | $22.55 | $23.23 |