- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $10.00 / $10.00
| Professional | | $10.00 | $10.00 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $5.00 / $8.32
| Professional | | $5.00 | $5.00 | $8.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.03 / $21.03 / $57.00
| Professional | | $21.03 | $21.03 | $57.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10.00 / $10.00 / $16.00
| Facility | | $10.00 | $10.00 | $16.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.00 / $24.00 / $329.00
| Professional | | $24.00 | $24.00 | $329.00 |