- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $20.00
| Professional | | $20.00 | $20.00 | $20.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8.00 / $13.60 / $13.60
| Facility | | $8.00 | $13.60 | $13.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7.00 / $8.00 / $9.30
| Professional | | $7.00 | $8.00 | $9.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $34.40
| Facility | | $20.00 | $20.00 | $34.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.22 / $39.22 / $39.22
| Professional | | $39.22 | $39.22 | $39.22 |