- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $87.10
| Facility | | $79.43 | $79.43 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $100.00 / $151.36
| Professional | | $77.62 | $100.00 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $104.71 / $123.03
| Professional | | $102.33 | $104.71 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $112.20 / $112.20 / $112.20
| Professional | 25 | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $104.71 / $104.71
| Professional | | $74.13 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.95 / $112.20 / $223.87
| Professional | | $54.95 | $112.20 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.18 / $91.20 / $120.23
| Professional | | $69.18 | $91.20 | $120.23 |