- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $56.23 / $77.62
| Professional | | $39.81 | $56.23 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.86 / $47.86 / $47.86
| Professional | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $75.86 / $75.86
| Professional | | $57.54 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $74.13 / $102.33
| Professional | | $52.48 | $74.13 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.90 / $66.07 / $81.28
| Facility | | $38.90 | $66.07 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.70 / $53.70 / $53.70
| Facility | | $53.70 | $53.70 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $58.88 / $100.00
| Professional | | $46.77 | $58.88 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $331.13
| Facility | | $331.13 | $331.13 | $331.13 |