- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.54 / $113.90 / $209.14
| Professional | | $55.54 | $113.90 | $209.14 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $72.23 / $124.85 / $300.00
| Professional | 25 | $72.23 | $124.85 | $300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.00 / $127.09 / $209.28
| Professional | | $80.00 | $127.09 | $209.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.69 / $110.24 / $181.54
| Professional | | $63.69 | $110.24 | $181.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.59 / $116.00 / $177.99
| Facility | | $73.59 | $116.00 | $177.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.00 / $150.04 / $214.04
| Professional | | $92.00 | $150.04 | $214.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.96 / $142.00 / $220.40
| Professional | | $102.96 | $142.00 | $220.40 |