- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.86 / $87.10 / $102.33
| Facility | | $75.86 | $87.10 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $95.50 / $117.49
| Professional | | $77.62 | $95.50 | $117.49 |
- 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
- $100.00 / $100.00 / $112.20
| Professional | 25 | $100.00 | $100.00 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $91.20 / $91.20
| Facility | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $131.83
| Professional | | $114.82 | $114.82 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $134.90 / $173.78
| Professional | | $85.11 | $134.90 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $95.50 / $131.83
| Professional | | $70.79 | $95.50 | $131.83 |