- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $44.67 / $120.23 / $177.83
| Facility | | $44.67 | $120.23 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $87.10 / $169.82
| Professional | | $40.74 | $87.10 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $51.29 / $60.26
| Professional | | $45.71 | $51.29 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $61.66 / $100.00
| Professional | | $44.67 | $61.66 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.44 / $44.67 / $93.33
| Professional | | $23.44 | $44.67 | $93.33 |
- 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
- $18.62 / $63.10 / $63.10
| Professional | | $18.62 | $63.10 | $63.10 |