- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.80 / $5.25 / $58.50
| Professional | | $3.80 | $5.25 | $58.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.40 / $1.75 / $2.00
| Facility | | $1.40 | $1.75 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.40 / $4.40 / $4.40
| Professional | | $4.40 | $4.40 | $4.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5.25 / $5.41 / $195.75
| Facility | | $5.25 | $5.41 | $195.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $6.76 / $6.89
| Professional | | $3.00 | $6.76 | $6.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3.00 / $6.76 / $6.89
| Professional | | $3.00 | $6.76 | $6.89 |