- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.31 / $26.31 / $26.31
| Professional | | $26.31 | $26.31 | $26.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.35 / $11.25 / $11.25
| Professional | | $10.35 | $11.25 | $11.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Facility | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $145.26 / $157.50
| Professional | | $100.00 | $145.26 | $157.50 |