- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Professional | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.60 / $12.60 / $12.60
| Facility | | $12.60 | $12.60 | $12.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.71 / $10.71 / $12.98
| Professional | | $10.71 | $10.71 | $12.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12.60 / $12.60 / $12.60
| Facility | | $12.60 | $12.60 | $12.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.71 / $12.60 / $12.98
| Professional | | $10.71 | $12.60 | $12.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.19 / $18.77 / $33.97
| Professional | | $9.19 | $18.77 | $33.97 |