- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.00 / $20.01 / $50.00
| Professional | | $19.00 | $20.01 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.50 / $34.50 / $100.00
| Professional | | $34.50 | $34.50 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.51 / $0.51 / $0.51
| Professional | | $0.51 | $0.51 | $0.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.00 / $40.00 / $134.00
| Facility | | $40.00 | $40.00 | $134.00 |
- 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
- $33.93 / $33.93 / $33.93
| Professional | | $33.93 | $33.93 | $33.93 |