- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.18 / $4.18 / $7.21
| Professional | | $4.18 | $4.18 | $7.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.38 / $70.55 / $108.23
| Facility | | $60.38 | $70.55 | $108.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.67 / $34.59 / $161.04
| Professional | | $27.67 | $34.59 | $161.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.55 / $18.55 / $18.55
| Facility | | $18.55 | $18.55 | $18.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7.59 / $18.55 / $18.55
| Facility | | $7.59 | $18.55 | $18.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.38 / $65.00 / $3,000.00
| Professional | | $34.38 | $65.00 | $3,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.55 / $18.55 / $18.55
| Facility | | $18.55 | $18.55 | $18.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.92 / $32.92 / $32.92
| Professional | | $32.92 | $32.92 | $32.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $50.00
| Facility | | $50.00 | $50.00 | $50.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.35 / $10.35 / $10.35
| Professional | | $10.35 | $10.35 | $10.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.35 / $10.35 / $10.35
| Professional | | $10.35 | $10.35 | $10.35 |