- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.62 / $103.75 / $130.54
| Professional | | $100.62 | $103.75 | $130.54 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $119.16 / $119.16 / $119.16
| Professional | 25 | $119.16 | $119.16 | $119.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.00 / $180.00 / $180.00
| Professional | | $146.00 | $180.00 | $180.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Facility | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.30 / $118.59 / $211.82
| Professional | | $82.30 | $118.59 | $211.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.61 / $87.70 / $245.56
| Professional | | $77.61 | $87.70 | $245.56 |