- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.21 / $112.21 / $112.21
| Professional | | $112.21 | $112.21 | $112.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.06 / $36.06 / $36.06
| Facility | | $36.06 | $36.06 | $36.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.65 / $36.06 / $37.14
| Professional | | $30.65 | $36.06 | $37.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.13 / $37.13 / $52.06
| Facility | | $37.13 | $37.13 | $52.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.22 / $76.54 / $107.46
| Professional | | $10.22 | $76.54 | $107.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8.80 / $87.89 / $219.73
| Professional | | $8.80 | $87.89 | $219.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.13 / $37.13 / $52.06
| Facility | | $37.13 | $37.13 | $52.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.65 / $36.06 / $37.14
| Professional | | $30.65 | $36.06 | $37.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.50 / $17.36 / $43.96
| Facility | | $2.50 | $17.36 | $43.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.31 / $102.18 / $181.05
| Professional | | $53.31 | $102.18 | $181.05 |