- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $64.57 / $93.33
| Professional | | $43.65 | $64.57 | $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
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.10 / $87.10 / $114.82
| Facility | | $87.10 | $87.10 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.10 / $63.10 / $100.00
| Professional | | $63.10 | $63.10 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.02 / $50.12 / $81.28
| Facility | | $38.02 | $50.12 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.71 / $50.12 / $75.86
| Professional | | $45.71 | $50.12 | $75.86 |