- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.01 / $50.01 / $50.01
| Professional | | $50.01 | $50.01 | $50.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.21 / $222.19 / $509.08
| Facility | | $104.21 | $222.19 | $509.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.46 / $36.46 / $36.46
| Professional | | $36.46 | $36.46 | $36.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.41 / $49.41 / $210.20
| Facility | | $49.41 | $49.41 | $210.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.41 / $33.86 / $46.48
| Professional | | $20.41 | $33.86 | $46.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $49.41 / $49.41 / $210.20
| Facility | | $49.41 | $49.41 | $210.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.41 / $33.86 / $46.48
| Professional | | $20.41 | $33.86 | $46.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.72 / $24.03 / $56.07
| Professional | | $17.72 | $24.03 | $56.07 |